Spinal stabilization device

ABSTRACT

A flexible connection unit for use in a spinal fixation device that includes: a longitudinal member having first and second ends and a flexible member interposed between the first and second ends, at least one of the first end and second end configured to be engaged by a first bone securing member; and at least one spacer located between the first and second ends, the spacer comprising a resilient element and a ring element encircling at least a portion of the resilient element, wherein the ring element is configured to be engaged by a second bone securing member.

CROSS-REFERENCE TO RELATED APPLICATIONS

The present application is a continuation-in-part of U.S. patentapplication Ser. No. 11/072,886, filed Mar. 3, 2005, which is acontinuation-in-part of U.S. patent application Ser. No. 11/009,097,filed Dec. 10, 2004, which is continuation-in-part of U.S. patentapplication Ser. No. 10/798,014, filed Mar. 10, 2004, which is acontinuation-in-part of U.S. patent application Ser. No. 10/728,566,filed on Dec. 5, 2003, which claims the benefit of priority under 35U.S.C. §119(a) to Korean Application Serial No. 2003-0066108, filed onSep. 24, 2003, the entirety of which is incorporated by referenceherein.

BACKGROUND OF THE INVENTION

1. Field of the Invention

The present invention relates to a method and system for stabilizing aspinal column and, more particularly, to a method and system of spinalfixation in which one or more screw type securing members are implantedand fixed into a portion of a patient's spinal column and a longitudinalmember including flexible, semi-rigid rod-like or plate-like structuresof various cross-sections (hereinafter referred to as “rods” or“plates”, respectively) are connected and fixed to the upper ends of thesecuring members to provide stabilization of the spinal column.

2. Description of the Related Art

Degenerative spinal column diseases, such as disc degenerative diseases(DDD), spinal stenosis, spondylolisthesis, and so on, need surgicaloperation if they do not take a turn for the better by conservativemanagement. Typically, spinal decompression is the first surgicalprocedure that is performed. The primary purpose of decompression is toreduce pressure in the spinal canal and on nerve roots located thereinby removing a certain tissue of the spinal column to reduce or eliminatethe pressure and pain caused by the pressure. If the tissue of thespinal column is removed the pain is reduced but the spinal column isweakened. Therefore, fusion surgery (e.g., ALIF, PLIF or posterolateralfusion) is often necessary for spinal stability following thedecompression procedure. However, following the surgical procedure,fusion takes additional time to achieve maximum stability and a spinalfixation device is typically used to support the spinal column until adesired level of fusion is achieved. Depending on a patient's particularcircumstances and condition, a spinal fixation surgery can sometimes beperformed immediately following decompression, without performing thefusion procedure. The fixation surgery is performed in most casesbecause it provides immediate postoperative stability and, if fusionsurgery has also been performed, it provides support of the spine untilsufficient fusion and stability has been achieved.

Conventional methods of spinal fixation utilize a rigid spinal fixationdevice to support an injured spinal part and prevent movement of theinjured part. These conventional spinal fixation devices include: fixingscrews configured to be inserted into the spinal pedicle or sacral ofthe backbone to a predetermined depth and angle, rods or platesconfigured to be positioned adjacent to the injured spinal part, andcoupling elements for connecting and coupling the rods or plates to thefixing screws such that the injured spinal part is supported and held ina relatively fixed position by the rods or plates.

U.S. Pat. No. 6,193,720 discloses a conventional spinal fixation device,in which connection members of a rod or plate type are mounted on theupper ends of at least one or more screws inserted into the spinalpedicle or sacral of the backbone. The connection units, such as therods and plates, are used to stabilize the injured part of the spinalcolumn which has been weakened by decompression. The connection unitsalso prevent further pain and injury to the patient by substantiallyrestraining the movement of the spinal column. However, because theconnection units prevent normal movement of the spinal column, afterprolonged use, the spinal fixation device can cause ill effects, such as“junctional syndrome” (transitional syndrome) or “fusion disease”resulting in further complications and abnormalities associated with thespinal column. In particular, due to the high rigidity of the rods orplates used in conventional fixation devices, the patient's fixed jointsare not allowed to move after the surgical operation, and the movementof the spinal joints located above or under the operated area isincreased. Consequently, such spinal fixation devices cause decreasedmobility of the patient and increased stress and instability to thespinal column joints adjacent to the operated area.

It has been reported that excessive rigid spinal fixation is not helpfulto the fusion process due to load shielding caused by rigid fixation.Thus, trials using load sharing semi-rigid spinal fixation devices havebeen performed to eliminate this problem and assist the bone fusionprocess. For example, U.S. Pat. Nos. 5,672,175, 5,540,688, and U.S. PubNo 2001/0037111 disclose dynamic spine stabilization devices havingflexible designs that permit axial load translation (i.e., along thevertical axis of the spine) for bone fusion promotion. However, becausethese devices are intended for use following a bone fusion procedure,they are not well-suited for spinal fixation without fusion. Thus, inthe end result, these devices do not prevent the problem of rigidfixation resulting from fusion.

To solve the above-described problems associated with rigid fixation,non-fusion technologies have been developed. The Graf band is oneexample of a non-fusion fixation device that is applied afterdecompression without bone fusion. The Graf band is composed of apolyethylene band and pedicle screws to couple the polyethylene band tothe spinal vertebrae requiring stabilization. The primary purpose of theGraf band is to prevent sagittal rotation (flexion instability) of theinjured spinal parts. Thus, it is effective in selected cases but is notappropriate for cases that require greater stability and fixation. See,Kanayama et al, Journal of Neurosurgery 95(1 Suppl):5-10, 2001,Markwalder & Wenger, Acta Neurochrgica 145(3):209-14.). Anothernon-fusion fixation device called “Dynesys” has recently beenintroduced. See Stoll et al, European Spine Journal 11 Suppl 2:S170-8,2002, Schmoelz et. al., J. of Spinal Disorder & Techniques 16(4):418-23,2003. The Dynesys device is similar to the Graf band except it uses apolycarburethane spacer between the screws to maintain the distancebetween the heads of two corresponding pedicle screws and, hence,adjacent vertebrae in which the screws are fixed. Early reports by theinventors of the Dynesys device indicate it has been successful in manycases. However, it has not yet been determined whether the Dynesysdevice can maintain long-term stability with flexibility and durabilityin a controlled study. Because it has polyethylene components andinterfaces, there is a risk of mechanical failure. Furthermore, due tothe mechanical configuration of the device, the surgical techniquerequired to attach the device to the spinal column is complex andcomplicated.

U.S. Pat. Nos. 5,282,863 and 4,748,260 disclose a flexible spinalstabilization system and method using a plastic, non-metallic rod. U.S.patent publication no. 2003/0083657 discloses another example of aflexible spinal stabilization device that uses a flexible elongatemember. These devices are flexible but they are not well-suited forenduring long-term axial loading and stress. Additionally, the degree ofdesired flexibility vs. rigidity may vary from patient to patient. Thedesign of existing flexible fixation devices are not well suited toprovide varying levels of flexibility to provide optimum results foreach individual candidate. For example, U.S. Pat. No. 5,672,175discloses a flexible spinal fixation device which utilizes a flexiblerod made of metal alloy and/or a composite material. Additionally,compression or extension springs are coiled around the rod for thepurpose of providing de-rotation forces on the vertebrae in a desireddirection. However, this patent is primarily concerned with providing aspinal fixation device that permits “relative longitudinal translationalsliding movement along [the] vertical axis” of the spine and neitherteaches nor suggests any particular designs of connection units (e.g.,rods or plates) that can provide various flexibility characteristics.Prior flexible rods such as that mentioned in U.S. Pat. No. 5,672,175typically have solid construction with a relatively small diameter inorder to provide a desired level of flexibility. Because they aretypically very thin to provide suitable flexibility, such prior art rodsare prone to mechanical failure and have been known to break afterimplantation in patients.

Therefore, conventional spinal fixation devices have not provided acomprehensive and balanced solution to the problems associated withcuring spinal diseases. Many of the prior devices are characterized byexcessive rigidity, which leads to the problems discussed above whileothers, though providing some flexibility, are not well-adapted toprovide long-term stability and/or varying degrees of flexibility.Therefore, there is a need for an improved dynamic spinal fixationdevice that provides a desired level of flexibility to the injured partsof the spinal column, while also providing long-term durability andconsistent stabilization of the spinal column.

Additionally, in a conventional surgical method for fixing the spinalfixation device to the spinal column, a doctor incises the midline ofthe back to about 10-15 centimeters, and then, dissects and retracts itto both sides. In this way, the doctor performs muscular dissection toexpose the outer part of the facet joint. Next, after the dissection,the doctor finds an entrance point to the spinal pedicle usingradiographic devices (e.g., C-arm flouroscopy), and inserts securingmembers of the spinal fixation device (referred to as “spinal pediclescrews”) into the spinal pedicle. Thereafter, the connection units(e.g., rods or plates) are attached to the upper portions of the pediclescrews in order to provide support and stability to the injured portionof the spinal column. Thus, in conventional spinal fixation procedures,the patient's back is incised about 10˜15 cm, and as a result, the backmuscle, which is important for maintaining the spinal column, is incisedor injured, resulting in significant post-operative pain to the patientand a slow recovery period.

Recently, to reduce patient trauma, a minimally invasive surgicalprocedure has been developed which is capable of performing spinalfixation surgery through a relatively small hole or “window” that iscreated in the patient's back at the location of the surgical procedure.Through the use of an endoscope, or microscope, minimally invasivesurgery allows a much smaller incision of the patient's affected area.Through this smaller incision, two or more securing members (e.g.,pedicle screws) of the spinal fixation device are screwed intorespective spinal pedicle areas using a navigation system. Thereafter,special tools are used to connect the stabilizing members (e.g., rods orplates) of the fixation device to the securing members. Alternatively,or additionally, the surgical procedure may include inserting a stepdilator into the incision and then gradually increasing the diameter ofthe dilator. Thereafter, a tubular retractor is inserted into thedilated area to retract the patient's muscle and provide a visual fieldfor surgery. After establishing this visual field, decompression and, ifdesired, fusion procedures may be performed, followed by a fixationprocedure, which includes the steps of finding the position of thespinal pedicle, inserting pedicle screws into the spinal pedicle, usingan endoscope or a microscope, and securing the stabilization members(e.g., rods or plates) to the pedicle screws in order to stabilize andsupport the weakened spinal column.

One of the most challenging aspects of performing the minimally invasivespinal fixation procedure is locating the entry point for the pediclescrew under endoscopic or microscopic visualization. Usually anatomicallandmarks and/or radiographic devices are used to find the entry point,but clear anatomical relationships are often difficult to identify dueto the confined working space. Additionally, the minimally invasiveprocedure requires that a significant amount of the soft tissue must beremoved to reveal the anatomy of the regions for pedicle screwinsertion. The removal of this soft tissue results in bleeding in theaffected area, thereby adding to the difficulty of finding the correctposition to insert the securing members and causing damage to themuscles and soft tissue surrounding the surgical area. Furthermore,because it is difficult to accurately locate the point of insertion forthe securing members, conventional procedures are unnecessarilytraumatic.

Radiography techniques have been proposed and implemented in an attemptto more accurately and quickly find the position of the spinal pediclein which the securing members will be inserted. However, it is oftendifficult to obtain clear images required for finding the correspondingposition of the spinal pedicle using radiography techniques due toradiographic interference caused by metallic tools and equipment usedduring the surgical operation. Moreover, reading and interpretingradiographic images is a complex task requiring significant training andexpertise. Radiography poses a further problem in that the patient isexposed to significant amounts of radiation.

Although some guidance systems have been developed which guide theinsertion of a pedicle screw to the desired entry point on the spinalpedicle, these prior systems have proven difficult to use and,furthermore, hinder the operation procedure. For example, prior guidancesystems for pedicle screw insertion utilize a long wire that is insertedthrough a guide tube that is inserted through a patient's back muscleand tissue. The location of insertion of the guide tube is determined byradiographic means (e.g., C-arm fluoroscope) and driven until a firstend portion of the guide tube reaches the desired location on thesurface of the pedicle bone. Thereafter, a first end portion of theguide wire, typically made of a biocompatible metal material, isinserted into the guide tube and pushed into the pedicle bone, while theopposite end of the wire remains protruding out of the patient's back.After the guide wire has been fixed into the pedicle bone, the guidetube is removed, and a hole centered around the guide wire is dilatedand retracted. Finally, a pedicle screw having an axial hole or channelconfigured to receive the guide wire therethrough is guided by the guidewire to the desired location on the pedicle bone, where the pediclescrew is screw-driven into the pedicle.

Although the concept of the wire guidance system is a good one, inpractice, the guide wire has been very difficult to use. Because it is arelatively long and thin wire, the structural integrity of the guidewire often fails during attempts to drive one end of the wire into thepedicle bone, making the process unnecessarily time-consuming andlaborious. Furthermore, because the wire bends and crimps duringinsertion, it does not provide a smooth and secure anchor for guidingsubsequent tooling and pedicle screws to the entry point on the pedicle.Furthermore, current percutaneous wire guiding systems are used inconjunction with C-arm flouroscopy (or other radiographic device)without direct visualization with the use of an endoscope or microscope.Thus, current wire guidance systems pose a potential risk ofmisplacement or pedicle breakage. Finally, because one end of the wireremains protruding out of the head of the pedicle screw, and thepatient's back, this wire hinders freedom of motion by the surgeon inperforming the various subsequent procedures involved in spinal fixationsurgery. Thus, there is a need to provide an improved guidance system,adaptable for use in minimally invasive pedicle screw fixationprocedures under endoscopic or microscopic visualization, which iseasier to implant into the spinal pedicle and will not hinder subsequentprocedures performed by the surgeon.

As discussed above, existing methods and devices used to cure spinaldiseases are in need of much improvement. Most conventional spinalfixation devices are too rigid and inflexible. This excessive rigiditycauses further abnormalities and diseases of the spine, as well assignificant discomfort to the patient. Although some existing spinalfixation devices do provide some level of flexibility, these devices arenot designed or manufactured so that varying levels of flexibility maybe easily obtained to provide a desired level of flexibility for eachparticular patient. Additionally, prior art devices having flexibleconnection units (e.g., rods or plates) pose a greater risk ofmechanical failure and do not provide long-term durability andstabilization of the spine. Furthermore, existing methods of performingthe spinal fixation procedure are unnecessarily traumatic to the patientdue to the difficulty in finding the precise location of the spinalpedicle or sacral of the backbone where the spinal fixation device willbe secured.

BRIEF SUMMARY OF THE INVENTION

The invention addresses the above and other needs by providing animproved method and system for stabilizing an injured or weakened spinalcolumn.

To overcome the deficiencies of conventional spinal fixation devices, inone embodiment, the inventor of the present invention has invented anovel flexible spinal fixation device with an improved construction anddesign that is durable and provides a desired level of flexibility andstability.

As a result of long-term studies to reduce the operation time requiredfor minimally invasive spinal surgery, to minimize injury to tissuesnear the surgical area, in another embodiment, the invention provides amethod and device for accurately and quickly finding a position of thespinal column in which securing members of the spinal fixation devicewill be inserted. A novel guidance/marking device is used to indicatethe position in the spinal column where the securing members will beinserted.

BRIEF DESCRIPTION OF THE DRAWINGS

FIG. 1 illustrates a perspective view of a spinal fixation device inaccordance with one embodiment of the invention.

FIG. 2 illustrates a perspective view of spinal fixation device inaccordance with another embodiment of the invention.

FIG. 3 illustrates an exploded view of the coupling assembly 14 of thepedicle screw 2 of FIGS. 1 and 2, in accordance with one embodiment ofthe invention.

FIG. 4 illustrates a perspective view of a flexible rod connection unitin accordance with one embodiment of the invention.

FIG. 5 illustrates a perspective view of a flexible rod connection unitin accordance with another embodiment of the invention.

FIG. 6 illustrates a perspective view of a flexible rod connection unitin accordance with a further embodiment of the invention.

FIG. 7 illustrates a perspective view of a pre-bent flexible rodconnection unit in accordance with one embodiment of the invention.

FIG. 8 illustrates a perspective, cross-sectional view of a flexibleportion of connection unit in accordance with one embodiment of theinvention.

FIG. 9 illustrates a perspective, cross-sectional view of a flexibleportion of connection unit in accordance with another embodiment of theinvention.

FIG. 10 illustrates a perspective, cross-sectional view of a flexibleportion of connection unit in accordance with a further embodiment ofthe invention.

FIG. 11 illustrates a perspective view of a flexible rod connection unitin accordance with one embodiment of the invention.

FIG. 12A illustrates a perspective view of a flexible connection unithaving one or more spacers in between two end portions, in accordancewith one embodiment of the invention.

FIG. 12B illustrates an exploded view of the flexible connection unit ofFIG. 12A.

FIG. 12C provides a view of the male and female interlocking elements ofthe flexible connection unit of FIGS. 12A and 12B, in accordance withone embodiment of the invention.

FIG. 13 shows a perspective view of a flexible connection unit, inaccordance with a further embodiment of the invention.

FIG. 14 illustrates a perspective view of a spinal fixation device inaccordance with another embodiment of the invention.

FIG. 15 illustrates an exploded view of the spinal fixation device ofFIG. 14.

FIG. 16A shows a perspective view of a flexible plate connection unit inaccordance with one embodiment of the invention.

FIG. 16B illustrates a perspective view of a flexible plate connectionunit in accordance with a further embodiment of the invention.

FIG. 16C shows a side view of the flexible plate connection unit of FIG.16A.

FIG. 16D shows a top view of the flexible plate connection unit of FIG.16A.

FIG. 16E illustrates a side view of the flexible plate connection unitof FIG. 16A having a pre-bent configuration in accordance with a furtherembodiment of the invention.

FIG. 17 is a perspective view of a flexible plate connection unit inaccordance with another embodiment of the invention.

FIG. 18 illustrates a perspective view of a flexible plate connectionunit in accordance with another embodiment of the invention.

FIG. 19 illustrates a perspective view of a hybrid rod-plate connectionunit having a flexible middle portion according to a further embodimentof the present invention.

FIG. 20 is a perspective view of a spinal fixation device that utilizesthe hybrid rod-plate connection unit of FIG. 19.

FIG. 21 illustrates a perspective view of the spinal fixation device ofFIG. 1 after it has been implanted into a patient's spinal column.

FIGS. 22A and 22B provide perspective views of spinal fixation devicesutilizing the plate connection units of FIGS. 16A and 16B, respectively.

FIG. 23A illustrates a perspective view of two pedicle screws insertedinto the pedicles of two adjacent vertebrae at a skewed angle, inaccordance with one embodiment of the invention.

FIG. 23B illustrates a structural view of a coupling assembly of apedicle screw in accordance with one embodiment of the invention.

FIG. 23C provides a perspective view of a slanted stabilizing spacer inaccordance with one embodiment of the invention.

FIG. 23D illustrates a side view of the slanted stabilizing spacer ofFIG. 23C.

FIG. 23E is a top view of the cylindrical head of the pedicle screw ofFIG. 23.

FIG. 24 illustrates a perspective view of a marking and guiding devicein accordance with one embodiment of the invention.

FIG. 25 is an exploded view of the marking and guidance device of FIG.24.

FIG. 26A provides a perspective, cross-section view of a patient's spineafter the marking and guiding device of FIG. 24 has been inserted duringsurgery.

FIG. 26B provides a perspective, cross-section view of a patient's spineas an inner trocar of the marking and guiding device of FIG. 24 is beingremoved.

FIGS. 27A and 27B illustrate perspective views of two embodiments of afiducial pin, respectively.

FIG. 28 is a perspective view of a pushing trocar in accordance with afurther embodiment of the invention.

FIG. 29A illustrates a perspective, cross-sectional view of a patient'sspine as the pushing trocar of FIG. 28 is used to drive a fiducial pininto a designate location of a spinal pedicle, in accordance with oneembodiment of the invention.

FIG. 29B illustrates a perspective, cross-sectional view of a patient'sspine after two fiducial pins have been implanted into two adjacentspinal pedicles, in accordance with one embodiment of the invention.

FIG. 30 is a perspective view of a cannulated awl in accordance with oneembodiment of the invention.

FIG. 31 is a perspective, cross-sectional view of a patient's spine asthe cannulated awl of FIG. 30 is being used to enlarge an entry hole fora pedicle screw, in accordance with one embodiment of the invention.

FIG. 32 provides a perspective view of fiducial pin retrieving device,in accordance with one embodiment of the invention.

FIG. 33 is a perspective view of a pedicle screw having an axialcylindrical cavity for receiving at least a portion of a fiducial pintherein, in accordance with a further embodiment of the invention.

FIG. 34 is a perspective, cross-sectional view of a patient's spineafter one pedicle screw has been implanted into a designated location ofa spinal pedicle, in accordance with one embodiment of the invention.

FIG. 35 is a perspective, cross-sectional view of a patient's spineafter two pedicle screws have been implanted into designated locationsof two adjacent spinal pedicles, in accordance with one embodiment ofthe invention.

FIG. 36A is perspective view of a flexible rod for spinal fixationhaving a spiral groove cut therein, in accordance with one embodiment ofthe present invention.

FIG. 36B provides a cross-sectional view of the flexible rod of FIG.36A, taken along lines B-B of FIG. 36A.

FIG. 37A illustrates a perspective view of a flexible rod for spinalfixation having transverse tunnels within the body of the rod, inaccordance with one embodiment of the invention.

FIG. 37B is a cross-sectional view of the flexible rod of FIG. 37A,taken along lines B-B of FIG. 37A.

FIG. 38A is a perspective view of a flexible rod for spinal fixationhaving a spiral groove cut therein and transverse tunnels in the body ofthe rod, in accordance with a further embodiment of the invention.

FIG. 38B is a top view of the flexible rod of FIG. 38A, from theperspective of lines B-B of FIG. 38A.

FIG. 39A is a perspective view of a flexible rod for spinal fixationhaving transverse tunnels within the body of the rod, in accordance withanother embodiment of the invention.

FIG. 39B is a cross-sectional view of the flexible rod of FIG. 39A,taken along lines B-B of that figure.

FIG. 39C is an alternative cross-sectional view of the flexible rod ofFIG. 39A, taken along lines B-B of that figure, having substantiallyorthogonal transverse tunnels in the body of the rod, in accordance witha further embodiment of the invention.

FIG. 40A illustrates a perspective view of a flexible rod for spinalfixation, in accordance with a further embodiment of the invention.

FIG. 40B illustrates a cross-sectional view of a flexible rod for spinalfixation in accordance with a further embodiment of the invention.

FIG. 41A illustrates a perspective view of a flexible longitudinalmember connection unit in accordance with one embodiment of theinvention.

FIG. 41B illustrates a perspective view of the connection unit of FIG.41A assembled with securing members.

FIG. 41C illustrates a perspective view of a flexible longitudinalmember trimmed to length and assembled with securing members.

FIG. 42A illustrates a side view of a flexible longitudinal memberconnection unit in accordance with a further embodiment of theinvention.

FIG. 42B illustrates a side view of a flexible longitudinal memberconnection unit in accordance with another embodiment of the invention.

FIG. 43A illustrates a side view of a flexible longitudinal memberconnection unit in accordance with another embodiment of the invention.

FIG. 43B illustrates a perspective view of a flexible longitudinalmember connection unit in accordance with another embodiment of theinvention.

FIG. 43C illustrates a side view of a flexible longitudinal memberconnection unit in accordance with another embodiment of the invention.

FIG. 43D illustrates a side view of a flexible longitudinal memberconnection unit in accordance with another embodiment of the invention.

FIG. 44 illustrates a perspective view of a flexible longitudinal memberconnection unit in accordance with a further embodiment of theinvention.

FIG. 45A illustrates a cross-section view of a flexible longitudinalmember connection unit in accordance with an embodiment of theinvention.

FIG. 45B illustrates a cross-section view of a flexible longitudinalmember made of two types of material in accordance with anotherembodiment of the invention.

FIGS. 46A-C illustrate perspective views of a metal-hybrid longitudinalmember with an elastomer cladding, in accordance with variousembodiments of the invention.

FIGS. 47A-B illustrate perspective views of a longitudinal member havingat least one spacer and an elastomer, in accordance with variousembodiments of the invention.

FIG. 48 illustrates a flexible connection unit having a spacer and anelastomer cladding, in accordance with another embodiment of theinvention.

FIG. 49 illustrates a flexible connection unit having a spacer and anelastomer cladding, in accordance with another embodiment of theinvention.

FIGS. 50A-D illustrate a variety of features for improved fixation ofthe elastomer cladding to a rigid surface, in accordance with variousembodiments of the invention.

FIGS. 51-52 illustrates two respective embodiments of a flexibleconnection unit having at least one spacer and an elastomer cladding, inaccordance with the invention.

FIG. 53 illustrates two flexible connection units as shown in FIG. 52attached to a patient's spine, in accordance with one embodiment of thepresent invention.

FIGS. 54-55 illustrates additional embodiments of a flexible connectionunit having at least one spacer and an elastomer cladding, in accordancewith the invention.

FIG. 56 illustrates an exploded view of a further embodiment of aflexible connection unit in accordance with the present invention.

FIG. 57 illustrates the flexible connection unit of FIG. 56 in anassembled state in accordance with an embodiment of the presentinvention.

FIG. 58 illustrates a cross sectional view of a metal-hybrid spacer inaccordance with an embodiment of the present invention.

FIGS. 59 a-b illustrate a perspective view and front cross-sectionalview of an embodiment of a D-ring metal ring in accordance with thepresent invention.

FIG. 60 illustrates a flexible connection unit in accordance with oneembodiment of the invention.

FIG. 61 illustrates a flexible connection unit in accordance with oneembodiment of the invention.

DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS

The invention is described in detail below with reference to the figureswherein like elements are referenced with like numerals throughout.

FIG. 1 depicts a spinal fixation device in accordance with oneembodiment of the present invention. The spinal fixation device includestwo securing members 2 (designated as 2′ and 2″), and a flexiblefixation rod 4 configured to be received and secured within a couplingassembly 14, as described in further detail below with respect to FIG.3. Each securing member 2 includes a threaded screw-type shaft 10configured to be inserted and screwed into a patient's spinal pedicle.As shown in FIG. 1, the screw-type shaft 10 includes an external spiralscrew thread 12 formed over the length of the shaft 10 and a conical tipat the end of the shaft 10 configured to be inserted into the patient'sspinal column at a designated location. Other known forms of thesecuring member 2 may be used in connection with the present inventionprovided the securing member 2 can be inserted and fixed into the spinalcolumn and securely coupled to the rod 4.

As described above, the spinal fixation device is used for surgicaltreatment of spinal diseases by mounting securing members 2 at desiredpositions in the spinal column. In one embodiment, the rod 4 extendsacross two or more vertebrae of the spinal column and is secured by thesecuring members 2 so as to stabilize movement of the two or morevertebrae.

FIG. 2 illustrates a perspective view of a spinal fixation device inaccordance with a further embodiment of the present invention. Thespinal fixation device of FIG. 2 is similar to the spinal fixationdevice of FIG. 1 except that the rod 4 comprises a flexible middleportion 8 juxtaposed between two rigid end portions 9 of the rod 4.

FIG. 3 provides an exploded view of the securing member 2 of FIGS. 1 and2 illustrating various components of the coupling assembly 14, inaccordance with one embodiment of the invention. As shown in FIG. 3, thecoupling assembly 14 includes: a cylindrical head 16 located at a topend of the screw-type shaft 10, a spiral thread or groove 18 formedalong portions of the inner wall surface of the cylindrical head 16, anda U-shaped seating groove 20 configured to receive the rod 4 therein.The coupling assembly 14 further comprises an outside-threaded nut 22having a spiral thread 24 formed on the outside lateral surface of thenut 22, wherein the spiral thread 24 is configured to mate with theinternal spiral thread 18 of the cylindrical head 16. In a furtherembodiment, the coupling assembly 14 includes a fixing cap 26 configuredto be mounted over a portion of the cylindrical head 16 to cover andprotect the outside-threaded nut 22 and more securely hold rod 4 withinseating groove 20. In one embodiment an inner diameter of the fixing gap26 is configured to securely mate with the outer diameter of thecylindrical head 16. Other methods of securing the fixing cap 26 to thecylindrical head, such as correspondingly located notches and groove(not shown), would be readily apparent to those of skill in the art. Inpreferred embodiments, the components and parts of the securing member 2may be made of highly rigid and durable bio-compatible materials such asstainless steel, iron steel, titanium or titanium alloy. Additionally oralternatively, non-metal biocompatible materials may also be utilizedsuch as polymers, elastomers, resins, ceramics, and composites thereof.Such materials are known in the art. As also known in the art, and usedherein, “bio-compatible” materials refers to those materials that willnot cause any adverse chemical or immunological reactions after beingimplanted into a patient's body.

As shown in FIGS. 1 and 2, in preferred embodiments, the rod 4 iscoupled to the securing means 2 by seating the rod 4 horizontally intothe seating groove 20 of the coupling means 14 perpendicularly to thedirection of the length of the threaded shaft 10 of securing member 2.The outside threaded nut 22 is then received and screwed into thecylindrical head 16 above the rod 4 so as to secure the rod 4 in theseating groove 20. The fixing cap 26 is then placed over the cylindricalhead 16 to cover, protect and more firmly secure the components in theinternal cavity of the cylindrical head 16. FIGS. 4-7 illustrateperspective views of various embodiments of a rod 4 that may be used ina fixation device, in accordance with the present invention. FIG. 4illustrates the rod 4 of FIG. 1 wherein the entire rod is made anddesigned to be flexible. In one embodiment, rod 4 comprises a metal tubeor pipe having a cylindrical wall 5 of a predefined thickness. Inalternative embodiments, the rod 4 may comprise a tube made from abiocompatible metal-synthetic hybrid material or entirely from abiocompatible synthetic material. Examples of biocompatible metals are:titanium, stainless steel, zirconium, tantalum, cobalt, chromium, nickeland alloys thereof. Examples of biocompatible synthetic materials are:polymers, elastomers, resins, plastics, carbon graphite and compositesthereof. Such materials are well known in the art.

In one embodiment, in order to provide flexibility to the rod 4, thecylindrical wall 5 is cut in a spiral fashion along the length of therod 4 to form spiral cuts or grooves 6. As would be apparent to one ofordinary skill in the art, the width and density of the spiral grooves 6may be adjusted to provide a desired level of flexibility. In oneembodiment, the grooves 6 are formed from very thin spiral cuts orincisions that penetrate through the entire thickness of the cylindricalwall of the rod 4. As known to those skilled in the art, the thicknessand material of the tubular walls 5 also affect the level offlexibility.

In one embodiment, the rod 4 is designed to have a flexibility thatsubstantially equals that of a normal back. Flexibility ranges for anormal back are known by those skilled in the art, and one of ordinaryskill can easily determine a thickness and material of the tubular walls5 and a width and density of the grooves 6 to achieve a desiredflexibility or flexibility range within the range for a normal back.When referring to the grooves 6 herein, the term “density” refers totightness of the spiral grooves 6 or, in other words, the distancebetween adjacent groove lines 6 as shown in FIG. 4, for example.However, it is understood that the present invention is not limited to aparticular, predefined flexibility range. In one embodiment, in additionto having desired lateral flexibility characteristics, the rigidity ofthe rod 4 should be able to endure a vertical axial load applied to thepatient's spinal column along a vertical axis of the spine in a uniformmanner with respect to the rest of the patient's natural spine.

FIG. 5 illustrates the rod 4 of FIG. 2 wherein only a middle portion 8is made and designed to be flexible and two end portions 9 are made tobe rigid. In one embodiment, metal end rings or caps 9′, having nogrooves therein, may be placed over respective ends of the rod 4 of FIG.4 so as make the end portions 9 rigid. The rings or caps 9′ may bepermanently affixed to the ends of the rod 4 using known methods such aspressing and/or welding the metals together. In another embodiment, thespiral groove 6 is only cut along the length of the middle portion 8 andthe end portions 9 comprise the tubular wall 5 without grooves 6.Without the grooves 6, the tubular wall 5, which is made of a rigidmetal or metal hybrid material, exhibits high rigidity.

FIG. 6 illustrates a further embodiment of the rod 4 having multiplesections, two flexible sections 8 interleaved between three rigidsections 9. This embodiment may be used, for example, to stabilize threeadjacent vertebrae with respect to each other, wherein three pediclescrews are fixed to a respective one of the vertebrae and the threerigid sections 9 are connected to a coupling assembly 14 of a respectivepedicle screw 2, as described above with respect to FIG. 3. Each of theflexible sections 8 and rigid sections 9 may be made as described abovewith respect to FIG. 5.

FIG. 7 illustrates another embodiment of the rod 4 having a pre-bentstructure and configuration to conform to and maintain a patient'scurvature of the spine, known as “lordosis,” while stabilizing thespinal column. Generally, a patient's lumbar is in the shape of a ‘C’form, and the structure of the rod 4 is formed to coincide to the normallumbar shape when utilized in the spinal fixation device of FIG. 2, inaccordance with one embodiment of the invention. In one embodiment, thepre-bent rod 4 includes a middle portion 8 that is made and designed tobe flexible interposed between two rigid end portions 9. The middleportion 8 and end portions 9 may be made as described above with respectto FIG. 5. Methods of manufacturing metallic or metallic-hybrid tubularrods of various sizes, lengths and pre-bent configurations arewell-known in the art. Additionally, or alternatively, the pre-bentstructure and design of the rod 4 may offset a skew angle when twoadjacent pedicle screws are not inserted parallel to one another, asdescribed in further detail below with respect to FIG. 23A.

Additional designs and materials used to create a flexible tubular rod 4or flexible middle portion 8 are described below with respect to FIGS.8-10. FIG. 8 illustrates a perspective, cross-sectional view of aflexible tubular rod 4, or rod portion 8 in accordance with oneembodiment of the invention. In this embodiment, the flexible rod 4, 8is made from a first metal tube 5 having a spiral groove 6 cut thereinas described above with respect to FIGS. 4-7. A second tube 30 havingspiral grooves 31 cut therein and having a smaller diameter than thefirst tube 5 is inserted into the cylindrical cavity of the first tube5. In one embodiment, the second tube 30 has spiral grooves 31 which arecut in an opposite spiral direction with respect to the spiral grooves 6cut in the first tube 5, such that the rotational torsioncharacteristics of the second tube 30 offset at least some of therotational torsion characteristics of the first tube 5. The secondflexible tube 30 is inserted into the core of the first tube to providefurther durability and strength to the flexible rod 4, 8. The secondtube 30 may be made of the same or different material than the firsttube 5. In preferred embodiments, the material used to manufacture thefirst and second tubes 5 and 30, respectively, may be any one orcombination of the following exemplary biocompatible metals: titanium,stainless steel, zirconium, tantalum, cobalt, chromium, nickel,aluminum, vanadium, and alloys thereof. In alternative embodiments, thetubes 5 and 30 may be made from a biocompatible metal-synthetic hybridmaterial or entirely from a biocompatible synthetic material. Examplesof biocompatible synthetic materials are: polymers, elastomers, resins,plastics, carbon graphite and composites thereof. Such materials arewell known in the art.

FIG. 9 illustrates a perspective, cross-sectional view of a flexible rod4, 8 in accordance with a further embodiment of the invention. In oneembodiment, the flexible rod 4, 8 includes an inner core made of abiocompatible metallic wire 32 comprising a plurality of overlappingthin metallic yarns, such as steel yarns, titanium yarns, ortitanium-alloy yarns. The wire 32 is encased by a metal, or metalhybrid, flexible tube 5 having spiral grooves 6 cut therein, asdiscussed above. The number and thickness of the metallic yarns in thewire 32 also affects the rigidity and flexibility of the rod 4, 8. Bychanging the number, thickness or material of the yarns flexibility canbe increased or decreased. Thus, the number, thickness and/or materialof the metallic yarns in the wire 32 can be adjusted to provide adesired rigidity and flexibility in accordance with a patient'sparticular needs. Those of ordinary skill in the art can easilydetermine the number, thickness and material of the yarns, inconjunction with a given flexibility of the tube 5 in order to achieve adesired rigidity v. flexibility profile for the rod 4, 8. In alternativeembodiments, the wire 32 and plurality of yarns may be made from abiocompatible metal-synthetic hybrid material or entirely frombiocompatible synthetic materials, as discussed above.

FIG. 10 shows yet another embodiment of a flexible rod 4 wherein theflexible tube 5 encases a non-metallic, flexible core 34. In variousembodiments, the core 34 may be made from, for example, knownbiocompatible metals, biocompatible shape memory alloys (e.g., NITINOL),or biocompatible synthetic materials such as carbon fiber, Poly EtherEther Ketone (PEEK), Poly Ether Ketone Ketone Ether Ketone (PEKKEK), orUltra High Molecular Weight Poly Ethylene (UHMWPE).

FIG. 11 illustrates a perspective view of another embodiment of theflexible rod 35 in which a plurality of wires 32, as described abovewith respect to FIG. 9, are interweaved or braided together to form abraided wire rod 35. The braided wire rod 35 can be made from the samematerials as the wire 32 discussed above. In addition to the variabilityof the rigidity and flexibility of the wire 32 as explained above, therigidity and flexibility of the braided rod 35 can be further modifiedto achieve desired characteristics by varying the number and thicknessof the wires 32 used in the braided structure 35. For example, in orderto achieve various flexion levels or ranges within the known flexionrange of a normal healthy spine, those of ordinary skill in the art caneasily manufacture various designs of the braided wire rod 35 by varyingand measuring the flexion provided by different gauges, numbers andmaterials of the wire used to create the braided wire rod 35. In afurther embodiment each end of the braided wire rod 35 is encased by arigid cap or ring 9′ as described above with respect to FIGS. 5-7, toprovide a rod 4 having a flexible middle portion 8 and rigid endportions 9. In a further embodiment (not shown), the braided wire rod 35may be utilized as a flexible inner core encased by a tube 5 havingspiral grooves 6 cut therein to create a flexible rod 4 or rod portion8, in a similar fashion to the embodiments shown in FIGS. 8-10. As usedherein the term “braid” or “braided structure” encompasses two or morewires, strips, strands, ribbons and/or other shapes of materialinterwoven in an overlapping fashion. Various methods of interweavingwires, strips, strands, ribbons and/or other shapes of material areknown in the art. Such interweaving techniques are encompassed by thepresent invention. In another exemplary embodiment (not shown), theflexible rod 35 includes a braided structure having two or more strips,strands or ribbons interweaved in a diagonally overlapping pattern.

FIG. 12A illustrates a further embodiment of a flexible connection unit36 having two rigid end portions 9′ and an exemplary number of spacers37 interposed between the end portions. In one embodiment, the rigid endportions 9′ and spacers can be made of bio-compatible metal,metal-hybrid, and/or synthetic materials as discussed above. Theconnection unit 36 further includes a flexible member or wire 32, asdiscussed above with respect to FIG. 9, which traverses an axial cavityor hole (not shown) in each of the rigid end portions 9′ and spacers 37.FIG. 12B illustrates an exploded view of the connection unit 36 thatfurther shows how the wire 32 is inserted through longitudinal axisholes of the rigid end portions 9′ and spacers 37. As further shown inFIG. 12B, each of the end portions 9′ and spacers 37 include a maleinterlocking member 38 which is configured to mate with a femaleinterlocking cavity (not shown) in the immediately adjacent end portion9′ or spacer 37. FIG. 12 C illustrates an exploded side view andindicates with dashed lines the location and configuration of the femaleinterlocking cavity 39 for receiving corresponding male interlockingmembers 38.

FIG. 13 shows a perspective view of a flexible connection unit 40 inaccordance with another embodiment of the invention. The connection unit40 is similar to the connection unit 36 described above, however, thespacers 42 are configured to have the same shape and design as the rigidend portions 9′. Additionally, the end portions 9′ have an exit hole orgroove 44 located on a lateral side surface through which the wire 32may exit, be pulled taut, and clamped or secured using a metal clip (notshown) or other known techniques. In this way, the length of theflexible connection unit 36 or 40 may be varied at the time of surgeryto fit each patient's unique anatomical characteristics. In oneembodiment, the wire 32 may be secured using a metallic clip or stopper(not shown). For example, a clip or stopper may include a small tubularcylinder having an inner diameter that is slightly larger than thediameter of the wire 32 to allow the wire 32 to pass therethrough. Afterthe wire 32 is pulled to a desired tension through the tubular stopper,the stopper is compressed so as to pinch the wire 32 contained therein.Alternatively, the wire 32 may be pre-secured using known techniquesduring the manufacture of the connection units 36, 40 having apredetermined number of spacers 37, 42 therein.

FIG. 14 depicts a spinal fixation device according to another embodimentof the present invention. The spinal fixation device includes: at leasttwo securing members 2 containing an elongate screw type shaft 10 havingan external spiral thread 12, and a coupling assembly 14. The devicefurther includes a plate connection unit 50, or simply “plate 50,”configured to be securely connected to the coupling parts 14 of the twosecuring members 2. The plate 50 comprises two rigid connection members51 each having a planar surface and joined to each other by a flexiblemiddle portion 8. The flexible middle portion 8 may be made inaccordance with any of the embodiments described above with respect toFIGS. 4-11. Each connection member 51 contains a coupling hole 52configured to receive therethrough a second threaded shaft 54 (FIG. 15)of the coupling assembly 14.

As shown in FIG. 15, the coupling assembly 14 of the securing member 2includes a bolt head 56 adjoining the top of the first threaded shaft 10and having a circumference or diameter greater than the circumference ofthe first threaded shaft 10. The second threaded shaft 54 extendsupwardly from the bolt head 56. The coupling assembly 14 furtherincludes a nut 58 having an internal screw thread configured to matewith the second threaded shaft 54, and one or more washers 60, forclamping the connection member 51 against the top surface of the bolthead 56, thereby securely attaching the plate 50 to the pedicle screw 2.

FIGS. 16A and 16B illustrate two embodiments of a plate connection unit40 having at least two coupling members 51 and at least one flexibleportion 8 interposed between and attached to two adjacent connectionmembers 51. As shown in FIGS. 16A and 16B, the flexible middle portion 8comprises a flexible braided wire structure 36 as described above withrespect to FIG. 11. However, the flexible portion 8 can be designed andmanufactured in accordance with any of the embodiments described abovewith respect to FIGS. 4-11, or combinations thereof. FIGS. 16C and 16Dillustrate a side view and top view, respectively, of the plate 50 ofFIG. 16A. The manufacture of different embodiments of the flexibleconnection units 50 and 58 having different types of flexible middleportions 8, as described above, is easily accomplished using knownmetallurgical, organic polymer, natural resin, or composite materials,and compatible manufacturing and machining processes.

FIG. 16E illustrate a side view of a pre-bent plate connection unit 50′,in accordance with a further embodiment of the invention. This plateconnection unit 50′ is similar to the plate 50 except that connectionmembers 51′ are formed or bent at an angle θ from a parallel plane 53during manufacture of the plate connection unit 50′. As discussed abovewith respect to the pre-bent rod-like connection unit 4 of FIG. 7, thispre-bent configuration is designed to emulate and support a naturalcurvature of the spine (e.g., lordosis). Additionally, or alternatively,this pre-bent structure may offset a skew angle when two adjacentpedicle screws are not inserted parallel to one another, as described infurther detail below with respect to FIG. 23A.

FIG. 17 illustrates a perspective view of a plate connection unit 60having two planar connection members 62 each having a coupling hole 64therein for receiving the second threaded shaft 44 of the pedicle screw2. A flexible middle portion 8 is interposed between the two connectionmembers 62 and attached thereto. In one embodiment, the flexible middleportion 8 is made in a similar fashion to wire 32 described above withrespect to FIG. 9, except it has a rectangular configuration instead ofa cylindrical or circular configuration as shown in FIG. 9. It isunderstood, however, that the flexible middle portion 8 may be made inaccordance with the design and materials of any of the embodimentspreviously discussed.

FIG. 18 illustrates a perspective view of a further embodiment of theplate 60 of FIG. 17 wherein the coupling hole 64 includes one or morenut guide grooves 66 cut into the top portion of the connection member62 to seat and fix the nut 58 (FIG. 15) into the coupling hole 64. Thenut guide groove 66 is configured to receive and hold at least a portionof the nut 58 therein and prevent lateral sliding of the nut 58 withinthe coupling hole 64 after the connection member 62 has been clamped tothe bolt head 56 of the pedicle screw 2.

FIG. 19 illustrates a perspective view of a hybrid plate and rodconnection unit 70 having a rigid rod-like connection member 4, 9 or 9′,as described above with respect to FIGS. 4-7, at one end of theconnection unit 70 and a plate-like connection member 51 or 62, asdescribed above with respect to FIGS. 14-18, at the other end of theconnection unit 70. In one embodiment, interposed between rod-likeconnection member 9 (9′) and the plate-like connection member 52 (64) isa flexible member 8. The flexible member 8 may be designed andmanufactured in accordance with any of the embodiments discussed abovewith reference to FIGS. 8-13.

FIG. 20 illustrates a perspective view of a spinal fixation device thatutilizes the hybrid plate and rod connection unit 70 of FIG. 19. Asshown in FIG. 20, this fixation device utilizes two types of securingmembers 2 (e.g., pedicle screws), the first securing member 2′ beingconfigured to securely hold the plate connection member 42(64) asdescribed above with respect to FIG. 15, and the second securing member2″ being configured to securely hold the rod connection member 4, 9 or9′, as described above with respect to FIG. 3.

FIG. 21 illustrates a perspective top view of two spinal fixationdevices, in accordance with the embodiment illustrated in FIG. 1, afterthey are attached to two adjacent vertebrae 80 and 82 to flexiblystabilize the vertebrae. FIGS. 22A and 22B illustrate perspective topviews of spinal fixation devices using the flexible stabilizing members50 and 58 of FIGS. 16A and 16B, respectively, after they are attached totwo or more adjacent vertebrae of the spine.

FIG. 23A illustrates a side view of a spinal fixation device after ithas been implanted into the pedicles of two adjacent vertebrae. As shownin this figure, the pedicle screws 2 are mounted into the pedicle bonesuch that a center axis 80 of the screws 2 are offset by an angle θ froma parallel plane 82 and the center axes 80 of the two screws 2 areoffset by an angle of approximately 2θ from each other. This type ofnon-parallel insertion of the pedicle screws 2 often results due to thelimited amount of space that is available when performing minimallyinvasive surgery. Additionally, the pedicle screws 2 may have a tendencyto be skewed from parallel due to a patient's natural curvature of thespine (e.g., lordosis). Thus, due to the non-parallel nature of how thepedicle screws 2 are ultimately fixed to the spinal pedicle, it isdesirable to offset this skew when attaching a rod or plate connectionunit to each of the pedicle screws 2.

FIG. 23B illustrates a side view of the head of the pedicle screw inaccordance with one embodiment of the invention. The screw 2 includes acylindrical head 84 which is similar to the cylindrical head 16described above with respect to FIG. 3 except that the cylindrical head84 includes a slanted seat 86 configured to receive and hold a flexiblerod 4 in a slanted orientation that offsets the slant or skew 0 of thepedicle screw 2 as described above. The improved pedicle screw 2 furtherincludes a slanted stabilizing spacer 88 which is configured to securelyfit inside the cavity of the cylindrical head 84 and hold down the rod 4at the same slant as the slanted seat 86. The pedicle screw 2 furtherincludes an outside threaded nut 22 configured to mate with spiralthreads along the interior surface (not shown) of the cylindrical head84 for clamping down and securing the slanted spacer 88 and the rod 4 tothe slanted seat 86 and, hence, to the cylindrical head 84 of thepedicle screw 2.

FIG. 23C shows a perspective view of the slanted spacer 88, inaccordance with one embodiment of the invention. The spacer 88 includesa circular middle portion 90 and two rectangular-shaped end portions 92extending outwardly from opposite sides of the circular middle portion90. FIG. 23D shows a side view of the spacer 88 that further illustratesthe slant from one end to another to compensate or offset the skew angleθ of the pedicle screw 2. FIG. 23E illustrates a top view of thecylindrical head 84 configured to receive a rod 4 and slanted spacer 88therein. The rod 4 is received through two openings or slots 94 in thecylindrical walls of the cylindrical head 84, which allow the rod 4 toenter the circular or cylindrical cavity 96 of the cylindrical head 84and rest on top of the slanted seat 86 formed within the circular orcylindrical cavity 94. After the rod 4 is positioned on the slanted seat86, the slanted stabilizing spacer 88 is received in the cavity 96 suchthat the two rectangular-shaped end portions 92 are received within thetwo slots 94, thereby preventing lateral rotation of the spacer 88within the cylindrical cavity 96. Finally, the outside threaded nut 22and fixing cap 26 are inserted on top of the slanted spacer 88 tosecurely hold the spacer 88 and rod 4 within the cylindrical head 84.

FIG. 24 illustrates a perspective view of a marking and guidance device100 for marking a desired location on the spinal pedicle where a pediclescrew 2 will be inserted and guiding the pedicle screw 2 to the markedlocation using a minimally invasive surgical technique. As shown in FIG.24, the marking device 100 includes a tubular hollow guider 52 whichreceives within its hollow an inner trocar 104 having a sharp tip 105 atone end that penetrates a patient's muscle and tissue to reach thespinal pedicle. the inner trocar 104 further includes a trocar grip 106at the other end for easy insertion and removal of the trocar 104. Inone embodiment, the marking and guidance device 100 includes a guiderhandle 108 to allow for easier handling of the device 100.

As shown in FIG. 25, the trocar 104 is in the form of a long tube orcylinder having a diameter smaller than the inner diameter of the hollowof the guider 102 so as to be inserted into the hollow of the tubularguider 102. The trocar 104 further includes a sharp or pointed tip 105for penetrating the vertebral body through the pedicle. The trocar 104further includes a trocar grip 106 having a diameter larger than thediameter of the hollow of the guider tube 102 in order to stop thetrocar 104 from sliding completely through the hollow. The trocar grip106 also allows for easier handling of the trocar 104.

FIGS. 26A and 26B provide perspective views of the marking and guidancedevice 100 after it has been inserted into a patient's back and pushedthrough the muscle and soft tissue to reach a desired location on thespinal pedicle. The desired location is determined using knowntechniques such as x-ray or radiographic imaging for a relatively shortduration of time. After the marking and guidance device 100 has beeninserted, prolonged exposure of the patient to x-ray radiation isunnecessary. As shown in FIG. 26B, after the guidance tube 102 ispositioned over the desired location on the pedicle, the inner trocar104 is removed to allow fiducial pins (not shown) to be inserted intothe hollow of the guidance tube 102 and thereafter be fixed into thepedicle.

FIGS. 27A and 27B illustrate perspective views of two embodiments of thefiducial pins 110 and 112, respectively. As mentioned above, thefiducial pins 110 and 112 according to the present invention areinserted and fixed into the spinal pedicle after passing through thehollow guider 102. The pins 110 and 112 have a cylindrical shape with adiameter smaller than the inner diameter of the hollow of the guidertube 102 in order to pass through the hollow of the guider 102. An endof each fiducial pin is a sharp point 111 configured to be easilyinserted and fixed into the spinal pedicle of the spinal column. In oneembodiment, as shown in FIG. 27B, the other end of the fiducial pinincorporates a threaded shaft 114 which is configured to mate with aninternally threaded tube of a retriever (not shown) for extraction ofthe pin 112. This retriever is described in further detail below withrespect to FIG. 32.

The fiducial pins 110, 112 are preferably made of a durable and rigidbiocompatible metal (e.g., stainless steel, iron steel, titanium,titanium alloy) for easy insertion into the pedicle bone. In contrast toprior art guide wires, because of its comparatively shorter length andmore rigid construction, the fiducial pins 110, 112 are easily driveninto the spinal pedicle without risk of bending or structural failure.As explained above, the process of driving in prior art guidance wireswas often very difficult and time-consuming. The insertion of thefiducial pins 110, 112 into the entry point on the spinal pedicle ismuch easier and convenient for the surgeon and, furthermore, does nothinder subsequent procedures due to a guide wire protruding out of thepatient's back.

FIG. 28 shows a cylindrical pushing trocar 116 having a cylindrical head118 of larger diameter than the body of the pushing trocar 116. Thepushing trocar 116, according to the present invention, is inserted intothe hollow of the guider 102 after the fiducial pin 110 or 112 has beeninserted into the hollow of the guider 102 to drive and fix the fiducialpin 110 or 112 into the spinal pedicle. During this pin insertionprocedure, a doctor strikes the trocar head 118 with a chisel or ahammer to drive the fiducial pin 110 and 112 into the spinal pedicle. Inpreferred embodiments, the pushing trocar 116 is in the form of acylindrical tube, which has a diameter smaller than the inner diameterof the hollow of the guider tube 112. The pushing trocar 116 alsoincludes a cylindrical head 118 having a diameter larger than thediameter of the pushing trocar 116 to allow the doctor to strike it witha chisel or hammer with greater ease. Of course, in alternativeembodiments, a hammer or chisel is not necessarily required. Forexample, depending on the circumstances of each case, a surgeon maychoose to push or tap the head 118 of the pushing trocar 116 with thepalm of his or her hand or other object.

FIG. 29A illustrates how a hammer or mallet 120 and the pushing trocar116 may be used to drive the pin 110, 112 through the hollow of theguider tube 102 and into the designated location of the spinal pedicle.FIG. 29B illustrates a perspective cross-sectional view of the spinalcolumn after two fiducial pins 110, 112 have been driven and fixed intotwo adjacent vertebrae.

After the fiducial pins 110 or 112 have been inserted into the spinalpedicle as discussed above, in one embodiment, a larger hole or areacentered around each pin 110, 112 is created to allow easer insertionand mounting of a pedicle screw 2 into the pedicle bone. The larger holeis created using a cannulated awl 122 as shown in FIG. 30. Thecannulated awl 122 is inserted over the fiducial pin 110, 112 fixed atthe desired position of the spinal pedicle. The awl 122 is in the formof a cylindrical hollow tube wherein an internal diameter of the hollowis larger than the outer diameter of the fiducial pins 110 and 112 sothat the pins 110, 112 may be inserted into the hollow of the awl 122.The awl 122 further includes one or more sharp teeth 124 at a first endportion for cutting and grinding tissue and bone so as to create thelarger entry point centered around the fiducial pin 110, 112 so that thepedicle screw 2 may be more easily implanted into the spinal pedicle.FIG. 31 illustrates a perspective cross-sectional view of a patient'sspinal column when the cannulated awl 122 is inserted into a minimallyinvasive incision in the patient's back, over a fiducial pin 110, 112 tocreate a larger insertion hole for a pedicle screw 2 (not shown). Asshown in FIG. 31, a retractor 130 has been inserted into the minimallyinvasive incision over the surgical area and a lower tubular body of theretractor 130 is expanded to outwardly push surrounding tissue away fromthe surgical area and provide more space and a visual field for thesurgeon to operate. In order to insert the retractor 130, in oneembodiment, the minimally invasive incision is made in the patient'sback between and connecting the two entry points of the guide tube 102used to insert the two fiducial pins 110, 112. Before the retractor 130is inserted, prior expansion of the minimally invasive incision istypically required using a series of step dilators (not shown), eachsubsequent dilator having a larger diameter than the previous dilator.After the last step dilator is in place, the retractor 130 is insertedwith its lower tubular body in a retracted, non-expanded state. Afterthe retractor 130 is pushed toward the spinal pedicle to a desireddepth, the lower tubular portion is then expanded as shown in FIG. 31.The use of step dilators and retractors are well known in the art.

After the cannulated awl 122 has created a larger insertion hole for thepedicle screw 2, in one embodiment, the fiducial pin 110, 112 isremoved. As discussed above, if the fiducial pin 112 has been used, aretrieving device 140 may be used to remove the fiducial pin 112 beforeimplantation of a pedicle screw 2. As shown in FIG. 32, the retriever140 comprises a long tubular or cylindrical portion having an internallythreaded end 142 configured to mate with the externally threaded topportion 114 of the fiducial pin 112. After the retriever end 142 hasbeen screwed onto the threaded end 114, a doctor my pull the fiducialpin 112 out of the spinal pedicle. In another embodiment, if thefiducial pin 110 without a threaded top portion has been used,appropriate tools (e.g., specially designed needle nose pliers) may beused to pull the pin 110 out.

In alternate embodiments, the fiducial pins 110, 112 are not extractedfrom the spinal pedicle. Instead, a specially designed pedicle screw 144may be inserted into the spinal pedicle over the pin 110, 112 withoutprior removal of the pin 110, 112. As shown in FIG. 33, the speciallydesigned pedicle screw 144 includes an externally threaded shaft 10 anda coupling assembly 14 (FIG. 3) that includes a cylindrical head 16(FIG. 3) for receiving a flexible rod-shaped connection unit 4 (FIGS.4-13). Alternatively, the coupling assembly 14 may be configured toreceive a plate-like connection unit as shown in FIGS. 14-20. Thepedicle screw 144 further includes a longitudinal axial channel (notshown) inside the threaded shaft 10 having an opening 146 at the tip ofthe shaft 10 and configured to receive the fiducial pin 110, 112therein.

FIG. 34 illustrates a perspective cross-sectional view of the patient'sspinal column after a pedicle screw 2 has been inserted into a firstpedicle of the spine using an insertion device 150. Various types ofinsertion devices 150 known in the art may be used to insert the pediclescrew 2. As shown in FIG. 34, after a first pedicle screw 2 has beenimplanted, the retractor 130 is adjusted and moved slightly to providespace and a visual field for insertion of a second pedicle screw at thelocation of the second fiducial pin 110, 112.

FIG. 35 provides a perspective, cross sectional view of the patient'sspinal column after two pedicle screws 2 have been implanted in tworespective adjacent pedicles of the spine, in accordance with thepresent invention. After the pedicle screws 2 are in place, a flexiblerod, plate or hybrid connection unit as described above with respect toFIGS. 4-20 may be connected to the pedicle screws to provide flexiblestabilization of the spine. Thereafter, the retractor 130 is removed andthe minimally invasive incision is closed and/or stitched.

FIG. 36A illustrates a perspective view of a flexible rod 200 for spinalfixation, in accordance with a further embodiment of the invention. Therod 200 is configured to be secured by securing members 2 as describedabove with reference to FIGS. 1-3. In preferred embodiments, the rod200, and rods 210, 220, 230 and 240 described below, are comprised of asolid, cylindrically-shaped rod made of known biocompatible materialssuch as: stainless steel, iron steel, titanium, titanium alloy, NITINOL,and other suitable metal, metal-synthetic hybrid or non-metal materialsor compositions, as discussed above. As shown in FIG. 36A, spiralgrooves 202 are cut or formed along at least a portion of the length ofthe cylindrical body of the rod 200. In an exemplary embodiment, thelength of the rod “l” may be between 4 and 8 centimeters (cm), and itscylindrical diameter “D” is between 4-8 millimeters (mm). The spiralgrooves 202 have a width “w” between 0.1 and 0.5 mm and a spiral angle θbetween 50 and 85 degrees from horizontal. The distance between spiralgrooves 202 can be between 3 and 6 mm. However, as understood by thoseskilled in the art, the above dimensions are exemplary only and may bevaried to achieve desired flexibility, torsion and strengthcharacteristics that are suitable for a particular patient orapplication.

FIG. 36B illustrates a cross-sectional view of the flexible rod 200,taken along lines B-B of FIG. 36A. As shown, spiral groove 202 is cuttoward the center longitudinal axis of the cylindrical rod 200. Thegroove may be formed continuously in a spiral fashion, as a helix or aninterrupted helix for a solid or hollow rod, or are as disconnectedcircumferential grooves for a solid rod. If hollow rods havedisconnected circumferential grooves formed in them, the grooves canonly partially penetrate the rod material to avoid discontinuities. Inone embodiment, the depth of the groove 202 is approximately equal tothe cylindrical radius of the rod 200, as shown in FIG. 36B, andpenetrates as deep as the center longitudinal axis of the cylindricalrod 200. However, the cross sectional area and shape of the rod, groovedepth, groove width, groove cross-section shape, and groove to groovespacing of the grooved portion of the longitudinal member can be variedto adjust mechanical and structural characteristics as desired. Forexample, deepening or widening grooves increases flexibility, whileincreasing groove-to-groove spacing decreases flexibility. This can beused to modify extent of rod bending at a fixed bending force, customtailor the bent shape of the rod, and equalize mechanical stresses inthe rod during bending in order to minimize material fatigue and improverod reliability.

FIG. 37A illustrates a flexible rod 210 for spinal fixation inaccordance with another embodiment of the invention. The rod 210includes a plurality of transverse holes or tunnels 212 drilled orformed within the body of the rod 210. In one embodiment, the tunnels212 pass through a center longitudinal axis of the cylindrical rod 210at an angle (d) from horizontal. The openings for each respective tunnel212 are located on opposite sides of the cylindrical wall of the rod 210and adjacent tunnels 212 share a common opening on one side of thecylindrical wall, forming a zigzag pattern of interior tunnels 212passing transversely through the central longitudinal axis of the rod210, as shown in FIG. 37A. In one embodiment, the diameter D of eachtunnel 212 may be varied between 0.2 to 3 mm, depending the desiredmechanical and structural characteristics (e.g., flexibility, torsionand strength) of the rod 210. However, it is understood that thesedimensions are exemplary and other diameters D may be desired dependingon the materials used and the desired structural and mechanicalcharacteristics. Similarly, the angle from horizontal Φ may be varied tochange the number of tunnels 212 or the distance between adjacenttunnels 212.

FIG. 37B illustrates a cross-sectional view of the flexible rod 210taken along lines B-B of FIG. 37A. The tunnel 212 cuts through thecenter cylindrical axis of the rod 210 such that openings of the tunnel212 are formed at opposite sides of the cylindrical wall of the rod 210.

FIG. 38A illustrates a perspective view of a flexible rod 220 for spinalfixation, in accordance with a further embodiment of the invention. Rod220 incorporates the spiral grooves 202 described above with referenceto FIGS. 36A and 36B as well as the transverse tunnels 212 describedabove with respect to FIGS. 37A and 37B. The spiral grooves 202 are cutinto the surface of the cylindrical wall of the rod 220 toward a centerlongitudinal axis of the rod 220. As discussed above, the dimensions ofthe spiral grooves 202 and their angle from horizontal θ (FIG. 36A) maybe varied in accordance with desired mechanical and structuralcharacteristics. Similarly, the dimensions of the transverse tunnels 212and their angle from horizontal Φ (FIG. 37A) may be varied in accordancewith desired mechanical and structural characteristics. In oneembodiment, the angles θ and Φ are substantially similar such that theopenings of the tunnels 212 substantially coincide with the spiralgrooves 202 on opposite sides of the cylindrical wall of the rod 220.

FIG. 38B shows a top view of the flexible rod 220 taken along theperspective indicated by lines B-B of FIG. 38A. As shown in FIG. 38B,the openings of the tunnels 212 coincide with the spiral grooves 202. Byproviding both spiral grooves 202 and transverse tunnels 212 within asolid rod 220, many desired mechanical and structural characteristicsthat are suitable for different patients, applications and levels ofspinal fixation may be achieved.

FIG. 39A illustrates a flexible rod 230 for spinal fixation, inaccordance with another embodiment of the invention. The rod 230includes a plurality of transverse tunnels 232 formed in the body of therod 230. The tunnels 232 are substantially similar to the tunnels 212described above with respect to FIGS. 37A and 37B, however, the tunnels232 are not linked together in a zigzag pattern. Rather, each tunnel 232is substantially parallel to its immediate adjacent tunnels 232 and theopenings of one tunnel 232 do not coincide with the openings of adjacenttunnels 232. As shown in FIG. 39A, the angle from horizontal Φ in thisembodiment is approximately 90 degrees. However, it is understood thatother angles Φ may be incorporated in accordance with the presentinvention. It is further understood that the dimensions, size and shapeof the tunnels 232 (as well as tunnels 212) may be varied to achievedesired mechanical and structural characteristics. For example, thecross-sectional shape of the tunnels 212 and 232 need not be circular.Instead, for example, they may be an oval or diamond shape, or otherdesired shape.

FIG. 39B illustrates a cross-sectional view of the rod 230 taken alonglines B-B of FIG. 39A. As shown in FIG. 39B, the transverse tunnel 232travels vertically and transversely through the center longitudinal axisof the rod 230. FIG. 39C illustrates a cross-sectional view of a furtherembodiment of the rod 230, wherein an additional transverse tunnel 232′is formed substantially orthogonal to the first transverse tunnel 232and intersect the first transverse tunnel 232 at the center, cylindricalaxis point. In this way, further flexibility of the rod 230 may beprovided as desired.

FIG. 40A illustrates a perspective view of a flexible rod 240, inaccordance with a further embodiment of the invention. The rod 240includes a plurality of interleaved transverse tunnels 232 and 242 whichare substantially orthogonal to each other and which do not intersect,as shown in FIG. 40A. In another embodiment, a cross-sectional view ofwhich is shown in FIG. 40B, adjacent tunnels 232 and 242 need not beorthogonal to one another. Each tunnel 232, 242 can be offset at adesired angle ω from its immediately preceding adjacent tunnel 232, 242.As can be verified by those of skill in the art, without undueexperimentation, by varying the dimensions of the tunnels, theirnumbers, and their angular directions with respect to one another,various desired mechanical and structural characteristics for flexiblerods used in spinal fixation devices may be achieved.

Sometimes for multi-level spinal fixation procedures, as shown in FIG.22B for example, it may be desirable for one spinal joint to be rigidlyfixed, while an adjacent spinal joint is dynamically (flexibly)stabilized. An embodiment of a longitudinal member to accomplish thisfunction is shown in FIG. 41A. Axial portion 254 of longitudinal member250 is grooved to provide increased flexibility for bending, whereasaxial portions 252 and 256 are not grooved and remain relatively rigid.The hole 258 is used to terminate the groove to prevent the formation ofcracks and improve reliability. The use of such holes of expandeddiameter to terminate grooves or slots in materials is well known in theart as a means of reducing peak mechanical stresses in materials andreducing the likelihood of material failure.

FIG. 41B illustrates the assembly of the rod 250 of FIG. 41A configuredto be secured to a patient's spine using at least three securing members2 (FIG. 3) having a flexible section 254 disposed between a first pairof securing members 2 and a non-flexible section 252 disposed between asecond pair for securing members 2.

As a further embodiment illustrated in FIG. 41C, an extended ungroovedsection 252 can accommodate a range of positions for a single securingmember 2 to be placed. In another embodiment, extended ungroovedsections can be symmetrically disposed at either end of a groovedsection. It is appreciated that the extended length of section 252provides a “one size fits all” longitudinal member 250 that canaccommodate various distances between the pedicle bones of adjacentvertebrae. As shown in FIG. 41C, the distance between the adjacentsecuring members, 2 and 2′, may be adjusted by selecting the location ofthe securing member 2 on section 252. Any excess length of section 252can then be trimmed away or removed.

Groove parameters such as groove depth, groove width, groovecross-section shape or profile, and groove to groove spacing of thegrooved portion 254 can be uniformly constant for uniform structural andmechanical characteristics along the axis of the grooved portion 254.Sometimes it is advantageous to have axially varying structural andmechanical characteristics for the longitudinal member in order tocontrol local mechanical stress levels, custom tailor bending shapes, oraffect resistance to bending in all bending directions or in selectedbending directions. The cross-sectional area of a cylindrical (forexample) hollow longitudinal member can be changed by changing the outerdiameter, while maintaining constant wall thickness for the hollowcylinder. Another embodiment is to modify the wall thickness byadjusting the internal diameter (i.e. the diameter of the cavity withinthe cylinder) while keeping the outer diameter of the hollow cylinderconstant. Still other embodiments simultaneously vary the externaldiameter and the internal diameter. It is easily seen how the abovearguments also apply to longitudinal members with shapes that are notcylindrical.

FIG. 42A illustrates a side view of a flexible, spirally groovedstabilization device 270 in accordance with an embodiment of theinvention. The spirally grooved section 271 has an expanded outerdiameter relative to ungrooved sections 262 and 262′. Whereas the spiralgroove imparts increased flexibility to section 271, it would alsoimpart greater per unit area material strain to section 271 relative toungrooved sections 262 and 262′ because of reduced cross-sectionalmaterial area in section 271, due to the presence of the grooves, if theouter diameter of spirally grooved section 271 were the same as theouter diameter of the ungrooved sections 262 and 262′. Expanding theouter diameter of section 271 can maintain acceptable material stresslevels during the flexing of the spirally grooved section 271 for boththe spirally grooved section 271, and the ungrooved sections 262 and262′.

In one embodiment, if the longitudinal member of FIG. 42A is hollow, theinner diameter of the cavity of the spirally grooved section 271 can bethe same as the inner diameter of the cavity of the ungrooved sections262 and 262′, whereas the outer diameter of the grooved flexible section271 is increased to reduce material stresses during bending and/or varythe flexibility of the grooved section 271.

FIGS. 42A and 42B (discussed below) illustrate examples of alongitudinal spinal stabilization device wherein a flexible section hasa different cross-sectional profile (e.g., outer diameter (in the caseof a cylindrical rod) or perimetric shape than that of corresponding endportions of the longitudinal stabilization device.

In a further embodiment, the cross-sectional profile (e.g., outerdiameter) of the grooved flexible section is kept the same as thecross-sectional profile (e.g., outer diameter) of the ungroovedsections, whereas the inner diameter of the cavity of the groovedflexible section is reduced relative to the inner diameters of thecavities of the ungrooved sections. This has a similar material stressreduction effect as described above.

In still further embodiments of the present invention, both inner andouter diameters of the grooved flexible section can be varied withrespect to the inner and outer diameters of the ungrooved sections toreduce material strain differences between the sections.

FIG. 42B illustrates a side view of another embodiment of the presentinvention that accomplishes variation in flexibility along alongitudinal axis by adjusting the cylindrical diameter orcross-sectional profile of the grooved section 266 (while maintaining aconstant inner cavity diameter for the case of a hollow longitudinalmember) in order to achieve reduced mechanical stresses in the vicinityof transition sections 264 and 264′, between the grooved section 266 andungrooved sections 262 and 262′, respectively. The outer diameter of thegrooved section 266 is smallest near a central portion of the groovedsection 266 and gradually expands toward the ungrooved sections 262.This provides more cross-sectional material area to distribute forcesthrough, thereby reducing per unit area stress in the regions of thegrooved section 266 near the transition sections 264 and 264′.

In another embodiment, axial variations of groove depth, groove width,groove cross-section shape, and groove to groove spacing can alsoachieve axially variant flexibility and mechanical characteristics,either alone or in combination with variance of the cylindricalcross-section as discussed above. For example: (i) tapering the groovedepth from a maximum near the center of a grooved section to near zeroat a boundary with a non grooved section (FIG. 43A); (ii) tapering thegroove width from a maximum near the center of a grooved section to nearzero at a boundary with a non grooved section (FIG. 43B); (iii)transitioning groove shape from one permitting maximum flexure near thecenter of a grooved section to a shape providing reduced flexure at aboundary with a non grooved section (FIG. 43C); or (iv) expanding grooveto groove spacing from a minimum near the center of a grooved section toa maximum at a boundary with a non grooved section (FIG. 43D).

FIG. 44 illustrates a longitudinal member with an elastomer cladding 278around the grooved section 276. In this embodiment, elastomer cladding278 covers only grooved section 276 and does not cover ungroovedsections 272. Also optional tapers 274 are formed in the longitudinalmember to provide for a smooth surface transition between clad andunclad sections. These optional tapers 274 also fixate the longitudinalposition of the cladding. Alternately the cladding may be extended ontoan ungrooved section 272. The elastomer cladding may (i) contact onlythe surface of the longitudinal member, (2) additionally penetrate intothe grooves of the longitudinal member, or (3) if the longitudinalmember is hollow, additionally penetrate to and at least partially fillthe inside of the longitudinal member. The elastomer cladding providesadditional control over the axial and flexural stability of thelongitudinal member, as well as providing a barrier between tissues andthe grooved section.

The elastomer cladding can consist of any of a variety of medical gradeelastomers, including, for example, silicone, polyurethane,polycarbonateurethane and silicone-urethane copolymers. The cladding canbe applied to the longitudinal member using a variety of techniques thatare well known in the art. In one technique, a thermoplastic orthermosetting resin can be injected into a heated mold surrounding thedesired section of the longitudinal member, while it is affixed within amold. An advantage of this injection molding process is that it canaccommodate cladding material that are not of sufficiently low viscosityfor application by alternate means at room temperature and pressure. Afurther advantage of injection molding is that the shape of the exteriorof the cladding is determined by the shape of the mold that is used.Another injection molding advantage is the reproducible penetration ofgroove interstices and the interior of hollow longitudinal members.Alternative molding techniques include compression molding and transfermolding.

Other cladding application methods include liquid injection molding,dipping, spraying, or painting with a mechanical applicator such as apaintbrush. These methods require that the cladding material be appliedin a low viscosity form. For an example a resin for application could besuspended in a solvent that evaporates after application. In anotherexample, the cladding material is applied in a low viscosity form andsubsequently cured through chemical, heat, or radiation methods. It issometime useful to mask parts of the longitudinal member whereapplication of the cladding material is not desired.

FIG. 45A illustrates a uniform cross-section of the flexible section ofa longitudinal member made of a material 277. FIG. 44B illustrates anon-uniform cross-section of a rod as a flexible section of alongitudinal member made of a material 277 that includes a section madeof another material 279. Clearly the rod of FIG. 45A will exhibit thesame bending behavior with applied force in both the x and y directions.If the materials of sections 320 and 330 have different bendingcharacteristics, the rod of FIG. 45B will exhibit different bendingbehavior with applied force for the x and y directions. For example, ifmaterial 279 in FIG. 45B is stiffer than material 277, the rod will bendmore easily in the x direction than in the y direction.

FIG. 46A illustrates another embodiment of a metal hybrid longitudinalmember with an elastomer cladding 278 around a wire portion 280 of thelongitudinal member. In this embodiment, elastomer cladding 278surrounds a braided wire 280 between two unclad end portions 262. Thewire may also be a single wire, multiple wires that are not braided (notshown), and may be coaxial with the end portions 262 or positionedeccentrically with respect to the longitudinal axis of the end portions262 as shown in FIG. 46B. The wire portion 280 may be straight as shownin FIG. 46A or curved, such as the wire 281 shown in FIG. 46C. Astraight wire 280 between end portions 262 provides greater resistanceto tension than a curved wire 281, which straightens as the longitudinalmember elongates under tension. In one embodiment, the end portions 262and wire 280 may be made from any desired and suitable biocompatiblemetal or metal-synthetic hybrid material discussed above with respect torod 4 and wire 32. In further embodiments, the cladding 278 may be madefrom any one or combination of suitable biocompatible synthetic ornon-metal materials discussed above.

The stiffness of the metal hybrid longitudinal member in FIGS. 46A-C maybe modified by varying the wire configuration within the elastomercladding 278 as described above, or by varying the physical geometry ofthe wire 280 and/or cladding 278. Those skilled in the art willrecognize that stiffness may be altered by changing the length and/ordiameter of the wire portion 280 and cladding 278, the ratio ofdiameters, or the number and placement of wires, for example.

FIG. 47A illustrates yet another embodiment of a flexible connectionunit having one or more spacers 37 between two rigid end portions 9′with an elastomer cladding 278 covering the one or more spacers 37. Theconnection unit further includes a wire 32, which traverses alongitudinal axial channel or hole in each of the spacers 37. In oneembodiment, as shown in FIG. 47A, the spacers 37 occupy substantiallyall of the space between the end portions 9′ such that the plurality ofspacers 37 are maintained in a substantially fixed position along alongitudinal axis direction between the end portions 9′. In other words,the spacers 37 do not move or slide substantially with respect to thewire 32 in the longitudinal direction because there is no space betweenthe end portions 9′ to do so. Each spacer 37 abuts an adjacent spacer 37and/or end portion 9′ such that it does not have room to slide withrespect to the wire 32 or other flexible member located in thelongitudinal axial channels of the spacers 37 between the end portions9′. A cladding 278 is formed around each spacer 37 or around the entiregroup of spacers 37. It is appreciated that the combination of thespacer 37 and cladding 278 forms a composite or hybrid spacer whereinthe spacer 37 provides a first material of the hybrid spacer and thecladding provides a second material of the hybrid spacer. In oneembodiment, the spacers 37 may be made from a biocompatible metal ormetal-synthetic hybrid materials, as discussed above, and the cladding278 may be made from any one or combination of suitable biocompatiblesynthetic or non-metal materials discussed above.

In another embodiment, the spacers 37 may be positioned along the wire32 such that there is room between adjacent spacers 37 and the endportions 9′, as shown in FIG. 47B. A cladding 278 is formed around thespacers 37 and the wire 32 such that substantially all of the spacebetween adjacent spacers 37 and the end portions 9′ is occupied by thecladding 278. Thus, the cladding 278 limits the motion of spacers 37 andthe wire 32 encased therein and provides additional rigidity to theflexible portion between the end portions 9′. The cladding 278, spacers37 and wire 32 may be made from any suitable material, including thosediscussed above with respect FIGS. 9, 10 and 47A, for example.

The cladding 278 in FIGS. 47A & B is shown to encapsulate all of each ofthe metal-hybrid spacers 37 between the end portions 9′. Those skilledin the art will recognize that the stiffness of the connection unit 36may be altered by cladding only a portion of the spacers 37, for examplethe space between the metal portion of the spacers 37 and the wire 32,or the spaces between the spacers 37 and between the spacers 37 and theend portions 9′.

The stiffness of the flexible connection unit described in the variousembodiments above may be altered by selecting various biocompatiblematerials. For example, the spacers 37 may be made of biocompatiblemetals (e.g. stainless steel, titanium, titanium alloys, tantalum,zirconium, cobalt chromium, and alloys of such materials). The spacers37 may also be made from materials comprising known rigid polymers (e.g.UHMWPE, PEEK and polyurethane) or ceramics (e.g. alumina or zirconia).

FIG. 48 illustrates a further embodiment of a flexible connection unit36 having a metal spacer 37 between rigid end portions 9′, with anelastomer cladding 278 surrounding at least part of the rigid spacer 37.The connection unit 36 further includes a flexible wire 32 positionedaxially through the spacers 37 and end portions 9′, wherein the spacer37, end portions 9′ and wire 32 are all physically separated by theelastomer cladding 278. In such an embodiment, all elements of theflexible connection unit can move relative to any other element undermechanical load, restricted only by the flex, stretch and compressioncharacteristics of the elastomer cladding 278. Thus, the size and shapeof the elements may be selected to withstand the loads on the humanspinal column and to allow normal motion of the vertebrae to which theconnection unit is attached. The metal spacer 37 and cladding 278together form a metal-synthetic hybrid or composite spacer, wherein theelastomer cladding 278 separates the metal spacer 37 from respectiverigid end portions 9′ and the metal wire 32 so that they do not rubagainst each other, thereby minimizing the generation of wear debris. Itis a further advantage of this embodiment that the connection unit isflexible in all directions or degrees of freedom, and therefore willpermit flexion, extension, lateral bending and axial rotation of thespinal column without a fixed or rigid mechanical restriction in anydirection. The elastomer cladding 278 in FIG. 48 is concentric with theflexible wire 32. In other embodiments (not shown), the wire 32 may beeccentrically located in the axial cavity of the spacer 37, or multiplewires 32, may be distributed throughout the axial cavity of the spacer37.

The wire 32 shown in FIG. 48 is physically separated at both ends fromthe end portions 9′. This may be accomplished by cladding the wire 32individually to create a metal-hybrid wire and assembling it with theend portions 9′ prior to cladding the spacer 37. Alternatively themetal-hybrid wire 32 may be clad by extruding elastomer around the wire32 or sliding it into a pre-formed extruded elastomer prior to assembly.The latter method of manufacturing has the advantage of allowing thewire 32 to slide along its axis within the elastomer cladding 278,thereby decreasing axial stiffness of the connection unit 36 relative toits flexural and shear stiffness. Those skilled in the art willrecognize that if the flexible wire 32 is free to slide as describedherein, then the flexural and shear stiffness of the connection unit 36may be altered by varying the diameter of the wire 32, with minimalchange in the axial stiffness of the connection unit 36. As known in theart, “flexural stiffness” relates to an amount that an object may bendand “shear stiffness” relates to an amount that an object can withstandlateral shear forces. “Axial stiffness” relates to an amount that anobject can be stretched or compressed.

FIG. 49 illustrates a flexible connection unit identical to FIG. 48,except that each end of the wire 32, is in contact with the end portions9′. In an alternate embodiment (not shown) one end of the wire 32 may bein contact with one end portion 9′, while the opposite end of the wire32 is separated from the other end portion 9′ by cladding as describedabove. Contact between the wire 32 and the end portions 9′ may besliding contact or fixed contact such as a press fit assembly, weldedassembly or brazed assembly. If both ends of the wire 32 are in fixedcontact with the end portions 9′, i.e. rigidly connected, the axialstiffness of the flexible connection unit is increased. A fixed contactat only one end of the wire 32, will have less effect on axial stiffnessof the connection unit.

FIGS. 48 and 49 illustrate a metal-hybrid spacer that includes a metalspacer 37 that circumferentially surrounds an elastomer cladding 278.Thus, the spacer 37 is primarily clad on its inside surface. Theseembodiments may be easily manufactured by holding the metal portion ofthe spacer 37 in place relative to the end portions 9′ in a mold, whilethe cladding 278 is applied. It is a further advantage of thisembodiment that the circumferentially located spacer 37 limits theexpansion and bending of the cladding 278 when the connection unit 36 ismechanically loaded. This limiting effect results in varying stiffnessof the connection unit 36, particularly in axial compression, bendingand shear. Those skilled in the art will recognize that stiffness of theconnection unit 36 may be varied by varying the inside diameter, lengthand number of spacers 37.

The elastomer cladding 278 in various embodiments may be formed by avariety of methods, including a variety of molding techniques,extrusion, dipping and painting as described earlier. In an alternateembodiment, the elastomer cladding 278 is molded in place using aninjection molded process and a biocompatible thermoplastic elastomersuch as polycarbonate urethane (PCU). PCU has advantages of favorablebiocompatibility, resistance to degradation and cracking, favorablefatigue properties and good adhesion to metal substrates in addition toits compatibility with the injection molding process. It is understood,however, that the cladding may be made from other suitable non-metalmaterials such as those described above. In further embodiments thesurface of the spacers 37 and end portions 9′ are prepared with one ormore features or surface treatments to improve the durability offixation of the elastomer cladding 278.

FIGS. 50A-D illustrate a variety of features for improved fixation ofthe elastomer cladding 278 to the surface of any rigid element 281. FIG.50A illustrates an undercut cavity in the rigid element 281 wherein thebody of the cavity 282 is larger than the neck 283, thereby capturingthe elastomer cladding 278 within the cavity 282. The cavity furtherincludes smaller undercut grooves 283 in the wall of the cavity forinterdigitation of the elastomer cladding 278. The undercut grooves 283and undercut cavity 282 may be utilized independently as well. Figure50B illustrates an external barb 284 on the rigid element 281 aroundwhich the elastomer cladding 278 is molded. FIG. 50C illustrates holes285 through the wall of the rigid element 281 through which theelastomer cladding 278 is molded. In one embodiment, the elastomercladding 278 covers both the interior and exterior surfaces of the wallaround the hole 285. Figure 50D illustrates a roughened surface 281′ ofthe rigid element 281 at the interface with the elastomer cladding 278.The roughened surface may be formed by a variety of methods, includingfor example, grit blasting, bead blasting, plasma spraying, chemicaletching and a variety of machining techniques. Any of the featuresillustrated in FIG. 50A-D may be used in combination with each other orin combination with surface treatments such as cleaning, passivation orchemical priming of the surface of the rigid element 281.

FIG. 51 illustrates a further embodiment of a spacer 37 and end portions9′ in which the spacer 37 and end portions 9′ are physically separatedby the elastomer cladding 278 and are configured such that theyreinforce the elastomer cladding 278 when the connection unit 36 ismechanically loaded. The spacer 37 and end portions 9′ includeoverlapping portions that physically limit the shear displacement of theend portions 9′ relative to each other without necessarily limitingaxial displacement of the end portions 9′ relative to each other. FIG.51 is exemplary of any number of combinations of shapes of a spacer 37and end portions 9′ that may be used to vary stiffness of the connectionunit 36 in one or more directions. Those skilled in the art willrecognize that this objective may be accomplished with overlappingfeatures or simply by increasing or reducing the spacing between therigid spacer 37 and the end portions 9′, or by adding additional spacers(not shown) and varying the spacing between adjacent spacers.

FIG. 52 illustrates another embodiment of a connection unit 284 havingtwo rigid end portions 285 and 286, and a middle portion in which aflexible member 287 connects end portions 285 and 286 and traverses anaxial hole in a metal-hybrid spacer 288. In one embodiment, metal-hybridspacer 288 is formed from at least one metal and one elastomer material,such that the metal part of the spacer 289 is configured to be acceptedand retained by a securing member such as a pedicle screw or laminarhook, and the elastomer part 290 of the spacer 288 is located onopposite sides of the metal part 289 and adjacent to respective endportions 285 and 286.

Referring to FIG. 52, when end portion 285 and metal spacer 289 areretained by respective securing members 2 (FIG. 2), for example, andaffixed to adjacent vertebrae, the connection unit 284 providesstability while simultaneously permitting motion to the vertebrae in sixdegrees of freedom (i.e., x-axis, y-axis, z-axis, pitch, roll and yaw).Although the end portions 285 and 286 substantially limit the motion ofthe metal-hybrid spacer 288 in the longitudinal axial direction, thecompressibility and elasticity of the elastomer part 290 on both sidesof the metal spacer 289 allows for stabilized motion of the metal spacer289 relative to the end portions 285 and 286 and/or flexible connectingmember 287 in each of the six degrees of freedom while also providing aresistance and stability of motion in each of the six degrees offreedom. Thus, in one embodiment, the connection unit provides a greaterrange of dynamically stabilized motion. Additionally, in one embodiment,the elastomer cladding 290 comprises a high-friction material thatresists sliding of the metal-hybrid spacer 288 on flexible middleportion 287, thereby providing further resistance to movement of themetal spacer 289 in the longitudinal axial direction. End portions 285and 286 are connected to respective ends of metal-hybrid spacer 288using any of the techniques discussed above or other known methods. Endportion 285 is configured to have sufficient length to be accepted andretained by a pedicle screw or other type of securing member. When themetal part 289 of the hybrid spacer 288 is coupled to and secured to asecuring member 2 (FIG. 3), for example, end portion 286 extends beyondthe securing member 2 (on the side opposite the space between the twosecuring members 2). Thus, end portion 286 is configured to be shortalong the axis of the connection unit 284, in order to minimize thelength of the connection unit 284 that extends beyond the securingmember 2.

In another embodiment (not shown), the flexible member 287 may belocated eccentric from the central longitudinal axis of the connectionunit 284. This eccentric configuration provides different levels ofstiffness, depending on the direction the connection unit 284 is bent.This may be advantageous if it is desired to provide a greater level ofstiffness when the connection unit 284 is flexed during spinal extension(e.g., when a patient bends backward) and a lesser level of stiffnesswhen the connection unit 284 is flexed during spinal flexion (e.g. whena patient bends forward). Additionally, or alternatively, differentlevels of stiffness v. direction of bending profiles may be achieved byapplying different amounts or thicknesses of cladding 290 on one side ofthe connection unit 284 than on other sides of the connection unit 284.Additionally, different amounts and/or types of cladding materials 290may be applied on either side of the spacer 289. Thus, the connectionunit 284 can provide different levels of stiffness in differentdirections of movement of the spacer 289 and, hence, varying levels ofstability can be provided to different directions of movement of avertebra secured to the spacer 289 via a securing member 2. In theseembodiments wherein the level of stiffness of the connection unit 284depends on the direction of bending, appropriate markings (e.g., laseretchings, physical features, etc.) may be placed on the connection unit284 to indicate the proper orientation of the connection unit 284 priorto securing the connection unit 284 to a patient's spine.

FIG. 53 illustrates the position of two connection units 284 after theyhave been implanted and secured to respective vertebrae of the spine.For each connection unit 284, the metal hybrid spacer 288 is fixed tothe inferior vertebra 291, and end portion 285 is fixed to the superiorvertebra 292. As shown in FIG. 53, the connection unit 284 providesallows for flexibility that takes into account the natural andanatomical motion of the spine. Because the invertebral disc 293 andfacet joint 294 are closer to the pedicle of the inferior vertebra 291than the pedicle of the superior vertebra 292, the flexible portion ofthe connection unit 284 provided by metal hybrid spacer 288, when it issecured to the inferior vertebra 291, is located off-center at or nearthe level of the natural joint in the spine, namely, the level of theintravertebral disc 293 and the facet joints 294. This flexibility atthe level of the natural joint allows for natural and anatomicallycorrect motion of the spine.

Of course, if flexibility is desired at additional areas this may beachieved by duplicating the metal-hybrid spacer 288 and connectingmember 287 at the opposite end of the connection unit 294 as shown inFIG. 54. Connection unit 295 is configured to be retained by respectivesecuring members attached to both spacers 288. The spacers 288 inconnection unit 295 may be longer than the spacer 288 in connection unit284 so that variability in the distance between vertebrae may beaccommodated. In further embodiments, the connection units describedabove can be extended to stabilize two or more joints or spinal motionsegments between three or more adjacent vertebrae, and affixed torespective vertebrae by three or more securing members (e.g., pediclescrews). Thus, in one embodiment, a connection unit includes a pluralityof metal-hybrid spacers 288 for providing flexible stabilization to aplurality of joints or spinal motion segments. Additionally, themetal-hybrid spacers 288 may be alternated with rigid end portions 285in any order or combination as needed by the surgeon. In this way, ahybrid multi-level or multi-spine segment connection unit may bedesigned, wherein each segment of the connection unit can provide adesired level of flexibility suited for each respective pair of inferiorand superior vertebrae to be stabilized. For example, a first section ofthe connection unit that stabilizes a first pair of vertebrae may bevery rigid, while a second section of the connection unit thatstabilizes a second pair of vertebrae may be more flexible when comparedto the first section. Numerous desired combinations of sections may beachieved to create a hybrid multi-level or multi-segment connectionunit, in accordance with the present invention.

In various embodiments, the flexible member 287 as shown in FIGS. 52, 54and 55 may be a solid member of rigid material, such as a biocompatiblemetal, preferably the same material as end portions 285 and 286integrally formed with end portion 285 and permanently fixed to endportion 286. Alternatively, connecting member 287 may be a wire,plurality of wires, braided cable or other structure for connecting endportions 285 and 286. It will be clear to one skilled in the art thatthe structure, length and diameter of the connecting member will affectthe flexibility of the connection unit 284. Similarly, the metal-hybridspacer 288 may be made of a biocompatible metal, preferably the samematerial as end portions 285 and 286, and a biocompatible elastomer, forexample, silicone or polyurethane and preferably polycarbonate urethane.The metal-hybrid spacer 288 is shown to be of substantially the sameoutside diameter as the rigid end portions 285 and 286. Alternatively,the elastomer part of the spacer 290 may be smaller or larger indiameter, or may be variable in diameter. It will be clear to oneskilled in the art that the flexibility of the connection unit 284 maybe changed by the selection of the cladding material and varying itsdimensions.

The non-metal or elastomer portion 290 of the metal-hybrid spacer 288may be attached to the surfaces of the respective end portions 285 and286, the metal spacer 289 and/or the flexible member 287 by a variety ofmethods including those shown in FIGS. 50A-50D. As shown in FIGS. 52-55,the elastomer cladding 290 maintains the metal spacer 289 in asubstantially fixed position with respect to the end portions 285 and286, while allowing some relative movement of the spacer 289 whenexternal forces cause the cladding to bend or compress in any direction.Thus, in one embodiment, the flexibility of the connection unit 284 issubstantially limited by the compressibility of the elastomer part 290of the hybrid spacer 288, which may be compressed in various directionsby the motion of the metal part 289 of the spacer 288, when the metalpart 289 is fixed to the vertebral bone by a securing member 2.

FIG. 55 illustrates an embodiment of a connection unit 296 with ametal-hybrid spacer 297 comprised of more than two different materials.The spacer 297 has a metal part 289 and an elastomer part 290 asdescribed in FIG. 52 and an additional bio-absorbable part 298, shownexternal to the elastomer part 290. The bio-absorbable part 298 of themetal-hybrid spacer is configured to substantially extend from each endof the metal part of the spacer 289 to the nearest end of respectiverigid end portions 285 and 286 and to restrict motion of the metal part297, until bio-absorbable part 298 is softened or degraded in the body.The bio-absorbable part of the spacer 298 may be comprised of at leastone material selected from a group of known bio-absorbable materialsconsisting of: polylactic acid, polyglycolic acid, polyglactic acid,polydioxanone, polyglyconate, calcium sulfate, calcium phosphate andcombinations thereof. Other known bio-absorbable materials, and eventhose that will be discovered in the future, may be utilized inaccordance with the present invention.

In one embodiment, the connection unit 296 can be used after a spinalfusion procedure. In many cases, it is desirable to rigidly secure thespine with implanted devices during the period immediately postoperativeto a fusion procedure, in order to allow the surgically placed bonegraft to heal and effectively fuse the adjacent vertebrae together.After fusion is successfully achieved, it is desirable to remove theimplanted devices to allow the bone graft to stabilize the spineindependently. This creates load on the graft site and healthyremodeling of the bone graft for secure fixation long term. However, itis highly undesirable to perform a second surgery to remove theimplanted devices. The connection unit 296 in FIG. 55 initially providesa more rigid stabilization following spinal fusion and then through anatural process the bio-absorbable portion 298 of the connection unit296 degrades and becomes absorbed by the body, thereby reducing thestiffness of the connection unit 296 and allowing the bone graft toshare a greater percentage of the load to stabilize the spine long term.The flexible connection unit 296 therefore allows a surgeon totransition the level of flexible stabilization from a first more rigidstate to a second less rigid state, with only one surgical procedure.Needless to say, the elimination of a surgical procedure is a tremendousadvantage to patients both from a health standpoint and a financial one.

The flexible connection unit 296 can be advantageously utilized in anysituation where it is desirable to provide varying levels of stability.Additionally, the relative amount and type of bio-absorbable materialincorporated into the connection unit 298 can be varied to alter theinitial stiffness of the connection unit 296 and the time required tofully absorb all of the bio-absorbable portion(s) 298. In oneembodiment, two or more different types of bio-absorbable materialshaving different stiffness characteristics and/or absorption times canbe utilized to provide transitions from multiple levels of stiffness. Ina further embodiment, a connection unit configured to stabilize multiplespine segments can incorporate bio-absorbable materials in one or moreflexible portions of the connection unit to provide varying states offlexibility by various flexible portions of the multi-spine segmentconnection unit. Additionally, the bio-absorbable material 298 may beapplied to completely encapsulate a flexible portion (e.g., themetal-hybrid spacer portion) of a connection unit, or simply coverselect portions of the connection unit, or fill gaps, spaces and/orchannels of the connection unit. In other words, the application of oneor more bio-absorbable materials 298 can be implemented in various waysto achieve desired initial and final stiffness characteristics for oneor more flexible portions of a connection unit. Additionally, it is notnecessary to combine bio-absorbable claddings 298 withnon-bio-absorbable claddings 290. Thus, in one embodiment, the elastomercladding 290 of the connection unit 296 illustrated in FIG. 55 may beomitted altogether or replaced by the bio-absorbable cladding 298, oranother bio-absorbable cladding (not shown) having different stiffnessand/or degradation/absorption characteristics.

FIG. 56 is an exploded view illustrating several features of aconnection unit 300 in accordance with one embodiment of the presentinvention. The connection unit 300 has first and second end portions 301and 302 and a middle portion 304 in which a flexible member 306 connectsend portions 301 and 302 and traverses an axial hole in a collar 308 andan axial hole in a metal-hybrid spacer 310. The second end portion 302is also referred to in this disclosure from time to time as the end cap302. The flexible member 306 can be formed integrally with the first endportion 301, so that the first end portion 301 and a flexible member 306are a rod-like element. In an alternative embodiment, the first endportion 301 and the flexible member 306 can be formed as two separateelements and secured together using any number of different securingmethods, such as by use of adhesives, machine threads, welding, laserwelding, press fitting, morse taper, or any other suitable method ofsecuring presently known or that will be known in the future.

The first end portion 301 and the flexible member 306 may be designed ina number of different ways for providing a desired stability to apatient's back, for example, substantially equal to that of a normalback. As is appreciated, varying the physical characteristics of thefirst end portion 301 and flexible member 306, such as respective sizesand material composition, can change the flexibility characteristics ofthe connection unit 300. For example, the first end portion 301 of theconnection unit 300, as shown in FIG. 56, has a larger diameter than theflexible member 306. However, the dimensions need not be so limited, asother embodiments can have other dimensions such having the first endportion 301 and flexible member 306 with the same diameter or theflexible member 306 having a larger diameter than the first end portion301. The first end portion 301 can also be rigid, semi-rigid orflexible. In one embodiment, the first end portion 301 is flexible, butless flexible than the flexible member 306. In addition, the first endportion 301 and the flexile member can be made of the same type ofmaterial or each can be made of different materials. In one embodiment,the first end portion 301 and flexible member 306 can be made of anysuitable biocompatible metal, metal-hybrid or synthetic materialdiscussed above with respect to the end portion 285 and flexible middleportion 287 described with reference to FIG. 52. It is also understoodthat the first end portion 301 and the flexible member 306 can be madein accordance with the design and material specifications of any of theembodiments previously discussed.

Further to FIG. 56, a transition area 312 can be provided where firstend portion 301 and the flexible member 306 connect. The transition area312 can be tapered or stepped so that the change in diameter between thefirst end portion 301 and the flexible member 306 is gradual. This canreduce or eliminate stress points caused by a sudden change in diameter,as is understood by those skilled in the art. Thus, the transition area312 can provide further strength to the device by, for example, reducingthe stress associated with a change in diameter between the first endportion 301 and the flexible portion. In one embodiment, the transitionarea 312 is integral with the first end portion 301 and the flexiblemember 306 and is made of the same material as the first end portion 301and the flexible member 306.

With reference to FIG. 57, which shows the connection unit 300 of FIG.56 in an assembled state, the collar 308 can be positioned between thefirst end portion 301 and the metal-hybrid spacer 310 and over some orall of the transition area 312 (FIG. 56). The collar 308 can provide aneven surface for an end of the metal-hybrid spacer 310 to abut against;as opposed to the spacer 310 contacting the transition area 312, whichcan provide an uneven contact surface. In one embodiment, the collar 308is made of the same type of material as the first end portion 301 andthe flexible member 306 discussed above, but may comprise a differenttype of material in other embodiments. Moreover, the collar 308 can besecured to the first end portion 301 or the collar 308 can be separateand “float” between the first end portion 301 and the spacer 310. Ifsecured, the collar 308 can be secured to the first end portion 301using any number of different securing methods, such as by use ofadhesives, machine threads, welding, laser welding, press fitting, morsetaper, or any other suitable method of securing presently known or knownin the future.

Further to FIG. 56, the metal-hybrid spacer 310 can be similar to themetal-hybrid spacer 310 of FIG. 52. The metal-hybrid spacer 310 caninclude at least one metal ring element 314 and at least one resilientelement or portion 316. As best seen in the cross-sectional view of thespacer 310 shown in FIG. 58, the resilient element 316 can comprisemultiple sections: a first bumper section 318 located on one side of themetal ring element 314, a second bumper section 320 located on the otherside of the metal ring element 314, and an internal bumper section 322located between the first and second bumpers 318 and 320 andsubstantially or completely inside the core of the metal ring element314. In one embodiment, each of the bumper sections 318, 320 and 322 isformed integral with one another. However, in other embodiments, thebumper sections 318, 320 and 322 can be non-integral or separate. Inalternative embodiments, the resilient element 316 can comprise morethat three bumper sections or fewer than three bumper sections forproviding desired flexibility characteristics to the connection unit300.

The resilient element 316 can consist of any of a variety of medicalgrade elastomers, including, for example, silicone, polyurethane,polycarbonateurethane and silicone-urethane copolymers. It is understoodthat the resilient element 316 can be made from other suitable non-metalmaterials such as those described above. In alternative embodiments, theresilient element 316 may be implemented as a helical metal spring, discspring, wave spring or other resilient structures. The resilient element316 can be formed on the sides of and within the core of the metal ringelement 314 using a variety of techniques that are well known in theart. In one technique, a thermoplastic or thermosetting resin can beinjected into a heated mold, while the metal ring element 314 is affixedwithin a mold. An advantage of this injection molding process is that itcan accommodate elastomer materials that are not of sufficiently lowviscosity for application by alternate means at room temperature andpressure. As is understood, the mold can be shaped to form the hollowaxial core of the spacer 310, or the hollow axial core can be formed bycutting out elastomer after the molding process is finished. A furtheradvantage of injection molding is that the shape of the exterior of thecladding is determined by the shape of the mold that is used.Alternative molding techniques include compression molding and transfermolding.

In accordance with one embodiment, the stiffness of one of the bumpersections 318, 320 or 322 can be different from one or more of the otherbumper sections 318, 320 or 322. Specifically, the stiffness of eachbumper can be independently tuned by adjusting the physical propertiesof the bumper. For example, as is appreciated by those skilled in theart, the stiffness can be modified by changing the length, diameter,ratio of diameters, placement and material composition of one or more ofthe bumper sections. Additionally, the resistance provided by bumperregions may be adjusted by changing the length of the spacing providedfor the resilient element between the first and second ends of theconnection unit, thereby compressively biasing the resilient element. Inone embodiment, the length of the spacing provided between the first andsecond ends may be adjusted by selecting a collar 308 of desireddimensions. Other techniques for adjusting this length would be readilyapparent to those of skill in the art.

Deformation zones can also be provided for controlling the deformationof the resilient element 316. Deformations zones can have the desiredeffect of providing a more predictive and consistent response tocompressive forces. For example, because most buckling of an resilientelement 316 having deformation zones occurs at the deformation zones, itcan be easier to predict the resilient element's 316 response. Incontrast, an absence of deformation zones can result in deformation atany number of different locations about the elastomer portion 316. Forexample, a resilient element 316 not having a defined deformation zonemay buckle at one location in response to a compressive force that isapplied a first time, but buckle at a different, second location whenthe exact same compressive force is applied a second time. As isappreciated by those skilled in the art, buckling at different locationscan provide different responses to the same compressive force.Consequently, it can be difficult to predict the response of anelastomer portion that does not have predefined deformation zones.

In one embodiment of the present invention, predefined deformation zonesare formed by contouring the shape of the resilient element 316 so thatit buckles at the predefined deformation zones. In the embodiment shownin FIG. 58, the first bumper 318 is contoured to have a reduced diameterits center, thereby defining a first predefined deformation zone 324,and the second bumper is contoured to have a reduced diameter itscenter, thereby defining a second predefined deformation zone 326.Accordingly, the resilient element 316 is configured to buckle at thefirst deformation zone 324 when ring element 314 translates in, forexample, a longitudinal axial direction toward the first deformationzone 324, and buckle at the second deformation zone 326 when the ringelement 314 translates in, for example, a longitudinal axial directiontoward the second deformation zone 326.

Similar to the metal part 289 referenced in FIG. 52, the metal ringelement 314 can be configured to be accepted and retained by a securingmember such as the securing member 2 described with reference to FIG. 3.To help properly position the ring element 314 in a securing member,shoulders 328 a and 328 b can be provided at respective ends of the ringelement 314, as best seen in FIGS. 57 and 58. For example, positioningthe head 16 (FIG. 3) of the securing member 2 between the shoulders 328a and 328 b can provide assurance that the ring element 314 ispositioned correctly in the securing member 2.

In one embodiment, the shoulders 328 a and 328 b may also be sized sothat a fastening member, such as the threaded nut 22 or the cap member26 of FIG. 3, cannot be fastened to a screw mount, such as head 16 ofFIG. 3, if the shoulders 328 a and 328 b are not positioned properly.For example, the shoulders 328 a and 328 b may be required to bepositioned on either side of the screw head 16; otherwise, if one of theshoulders 328 a or 328 b is inside the screw head 16, then the nut 22cannot be properly inserted into the head 16 because the shoulder 328extends at least partially into the area of the head 16 configured toreceive the nut 22. As a result, a person securing the ring element 314to the securing member 2 should realize that the ring element 314 is notpositioned properly in the head 16 if the nut 22 cannot be properlyfastened to the securing member 2. Thus, if unable to fasten the nut 22,the person installing the connection unit 300 should reposition the ringelement 314 within the head 16.

With further reference to FIG. 58, in particular the magnified view ofthe spacer 310, the interior edges of the ring element 314 may betrumpeted. As used herein, the term trumpeted can be defined as roundedout or flared. In one embodiment, the inner diameter of the ring element314 is substantially constant in the center portion of the metal ringelement 314, but increases (i.e., is trumpeted) near the ends of thering element 314. In a further embodiment, the inner diameter issmallest at the center and gradually increases toward the ends of thering element 314 so that the longitudinal cross-sectional shape of theinterior surface of the ring element 314 has a constant radius ofcurvature.

Trumpeting the ends of the ring element 314 can provide severalbenefits. First, trumpeting the ends can provide more surface areabetween the ring element 314 and the resilient element 316 than if theinner surface of the ring element 314 had, for example, sharp corners atthe edges. The additional surface area can result in less contactstress, which can reduce the likelihood of the ring element 314 cuttingthe resilient element 316, especially at the edges of the ring element314. Trumpeting the ends can also facilitate toggling rotation of thering element 314. Toggling rotation permits a more natural motion of thespine, and is discussed in more detail below.

FIGS. 59 a and 59 b depict a further embodiment of a ring element 414 inaccordance with the present invention. FIG. 59 a is a perspective viewof the ring element 414 and FIG. 59 b is a front cross-sectional view ofthe ring element 414. As shown, the ring element 414 is similar to thering element 314 shown in FIGS. 56-58, except that the ring element 414has a generally D-like cross-sectional shape. The ring element 414 isreferred to in this disclosure from time to time as a “D-ring.” Also,similar to the ring element 314, the D-ring 414 can have trumpeted ends330 as well as shoulders 328 a, 328 b. It is believed that thecross-sectional shape of the D-ring 414 can distribute a compressiveload resulting from a locking cap (e.g. nut 22 of FIG. 3) compressingdown onto a flat top surface 332 of the ring 414 better than most otherconfigurations. The D-ring's 414 ability to better distribute this typeof compressive load can reduce or altogether avoid localized buckling,thereby enabling higher locking torques and the use of thinner ringwalls.

Referring back to FIG. 56, the end cap 302 is fastened to an end of theflexible member 306 and retains the collar 308 and the spacer 310between the first end 301 and the end cap 302. In one embodiment, theend cap 302 has an axial core with internal threads (not shown). The endcap 302 can be secured to the flexible member 306 by threading theinternal threads with corresponding external threads 334 located at anend of the flexible member 306. Once threaded together, an outside seam(not shown) between the flexible member 306 and the end cap 302 can belaser welded to further secure the end cap 302 to the flexible member306. In other embodiments, the end cap 302 may be secured to the firstend portion 301 using any number of different securing methods,including but not limited to press fitting, use of adhesives, swagingand morse taper.

With reference to FIG. 56, a shoulder 336 can be formed on the flexiblemember 306 for preventing the end cap 302 from traveling along thelongitudinal axis of the flexible member 306 past a predetermineddistance when being secured to the flexible member 306. Advantageously,the predetermined distance can be associated with a desired preload onthe spacer 310. This is because when assembling the connection unit 300,the resilient element 316 of the spacer 310 may be compressed to someextent after the end cap 302 is attached. This may happen, for example,if the spacer 310 in its uncompressed state has a longitudinal lengththat is longer than the length between the collar 308 and the end cap302. Accordingly, the amount the spacer 310 is compressed after the endcap 302 is attached can correspond to a preload amount.

In one embodiment, the spacer 310 having a preload provides a firstlevel of resistance to a longitudinal movement of the metal ring 314until the preload is overcome. Once the preload is overcome, the spacer310 provides a second level of resistance, which is less than the firstlevel of resistance. Because it is believed that most people dealingwith spine pain typically feel most the their pain during an initialrange of motion of the spine, but do not feel as much pain after theinitial range of motion, the spacer 310 can be configured with a preloadthat provides more support (e.g. more resistance) during the initial,painful range of motion and less support (e.g. less resistance) afterthe initial range of motion.

As described above, in one embodiment, the spacer 310 is not affixed tothe collar 308, end cap 302 or of flexible member 306 and, therefore,can separate from the end cap 302 or collar 308 after a preloadassociated with the spacer 310 has been overcome. Accordingly, in thisembodiment, the spacer 310 only resists compression and does not resistmotion by tension or elongation. By configuring the spacer 310 to resistcompression only, it is believed that the connection unit 300 canprovide better dynamic support during motion of the spine.

Referring to FIG. 57, when end portion 301 and spacer 310 are retainedby respective securing members 2 (FIG. 2), for example, and affixed toadjacent vertebrae, the connection unit 300 provides stability whilesimultaneously permitting motion to the vertebrae in six degrees offreedom (i.e., x-axis, y-axis, z-axis, pitch, roll and yaw). Movement ofthe metal ring element 314 in a pitch, roll, yaw or combination thereofmay also be referred to in this disclosure as a “toggling” motion.Although the end portions 301 and 302 substantially limit the motion ofthe spacer 310 in the longitudinal axial direction, the compressibilityand elasticity of the resilient element 316 on both sides of the metalring element 314 and between the metal ring element 314 and the flexiblemember 306 allows for stabilized motion of the metal ring element 314relative to the end portions 301 and 302 and/or flexible member 306 ineach of the six degrees of freedom while also providing a resistance andstability of motion in each of the six degrees of freedom. Thus, in oneembodiment, the connection unit 300 provides a greater range ofdynamically stabilized motion. Additionally, in one embodiment, theresilient element 316 permits sliding of the metal-hybrid spacer 310 onflexible member 306, thereby providing further movement of the metalring element 314 in the longitudinal axial direction. In one embodiment,the metal hybrid spacer 310 floats between end portions 301 and 302(i.e. the spacer 310 is not affixed to respective ends portions 301 and302 or collar 308) so that the metal-hybrid spacer 310 can be physicallyseparated from the end cap 302 or collar 308 in response to a sufficientlongitudinal axial force.

FIG. 60 illustrates an alternative embodiment of a connection unit 500in accordance with the present invention. Connection unit 500 is similarto connection unit 300 of FIG. 56, except that the spacer 310 iscomprised of single resilient element 510 rather than the metal-hybridspacer 310 shown in FIG. 56. In this embodiment, the single resilientelement 510 is configured to be directly received within acorrespondingly shaped securing head of a bone securing member (e.g.,ring-shaped head of a pedicle screw). Thus, the securing head of thebone securing member assumes the functionality of the ring element 314of the metal-hybrid spacer. When the resilient element 510 is receivedwithin and secured to the securing head of a bone securing member, theresilient element 510 functions to provide dynamic resistance againstrelative motion of the bone securing member in at least five degrees offreedom, excluding rotation about a longitudinal axis of the connectionunit. In an alternative embodiment, the resilient element 510 providessufficient friction against the flexible member 306 located within theaxial channel of the resilient element 510 so as to provide resistanceto motion of the bone securing member in all six degrees of freedom.

FIG. 61 is a perspective view of a flexible connection unit 600, inaccordance with another embodiment of the invention. Connection unit 600is similar to connection units 300 and 500 of FIGS. 56 and 60,respectively, except that the spacer 610 of connection unit 600 includesa ring element 612 interposed between resilient spring elements 614 and616. The ring element 612 is configured to be engaged with a securinghead of a bone securing member (e.g., pedicle screw) and the resilientspring elements 614 and 616 provide resistance to longitudinal movement(e.g., sliding) of the ring element 612 along a longitudinal axis of theflexible element 306 (FIG. 56). As shown in FIG. 61, the spacer 610 ispositioned between a first end 301 and a second end 302, comprising endcap 302, as described above. A collar 308 is interposed between thespacer 610 and the first end 301. As discussed above, the collar 308 canprovide an even surface for an end of the metal-hybrid spacer 310 toabut against; as opposed to the spacer 310 contacting a transition area312 (FIG. 56), which can provide an uneven contact surface.

Various embodiments of the connection units discussed in this disclosurecan have several other advantages. First, some of the embodiments have asimilar profile to conventional spinal fixation devices consisting of ametal rod secured to vertebrae via securing members. Because embodimentsof connection units in accordance with the present invention can have asimilar profile to a metal rod, the embodiments disclosed herein canhave the advantage of being installed using conventional spinal fixationinstrumentation. Furthermore, the low profile associated with many ofthe connection unit embodiments occupies less room in the patient,thereby resulting in less interference with the patient's range ofmotion, among other things.

Various embodiments of the invention have been described above. However,those of ordinary skill in the art will appreciate that the abovedescriptions of the preferred embodiments are exemplary only and thatthe invention may be practiced with modifications or variations of thedevices and techniques disclosed above. Those of ordinary skill in theart will know, or be able to ascertain using no more than routineexperimentation, many equivalents to the specific embodiments of theinvention described herein. Such modifications, variations andequivalents are contemplated to be within the spirit and scope of thepresent invention as set forth in the claims below.

What is claimed is:
 1. A flexible connection unit for use in a spinalfixation device, the flexible connection unit comprising: a longitudinalmember having a first end portion, a second end portion and a flexiblemember interposed at least partially between the first and second endportions, at least one of the first end portion or the second endportion configured to be engaged by a first bone securing member; and aspacer located at least partially between the first and second endportions, the spacer comprising: (1) a rigid ring element having alength and having a first inner bore extending the length of the ringelement; and (2) a resilient element including a first resilientportion, a second resilient portion and a connecting portion, the firstresilient portion is configured to abut the first end portion, thesecond resilient portion is configured to abut the second end portion,and the connecting portion extends through the first inner boreconnecting the first resilient portion to the second resilient portionsuch that the ring element is spaced apart from the first and second endportions, and the resilient element further defines a second inner boreconfigured to receive the flexible member such that the flexible memberextends through the first and second inner bores.
 2. The flexibleconnection unit of claim 1 wherein at least one interior edge of thering element is rounded.
 3. The flexible connection unit of claim 2wherein both interior edges of the ring element are rounded.
 4. Theflexible connection unit of claim 1 wherein the ring element has acircular cross-sectional shape.
 5. The flexible connection unit of claim1 wherein a cross-sectional profile of the flexible member is smallerthan a cross sectional profile of at least one of the first or secondend portions.
 6. The flexible connection unit of claim 1 wherein theresilient element is made of a material comprising organic polymer,elastomer, naturally occurring resin, or composite material.
 7. Theflexible connection unit of claim 1 wherein the connection unit isconfigured in the profile of a cylindrical rod.
 8. The flexibleconnection unit of claim 1 wherein the spacer is made of a materialcomprising metal, metal alloy, organic polymer, naturally occurringresin, thermoplastic or composite material.
 9. The flexible connectionunit of claim 1 wherein the ring element is made of a materialcomprising metal, metal alloy or composite material.
 10. The flexibleconnection unit of claim 1 wherein the flexible member comprises aflexible wire or bundle of wires.
 11. The flexible connection unit ofclaim 6 wherein the resilient element comprises elastomeric cladding.12. The flexible connection unit of claim 1 wherein the first and secondend portions of the longitudinal member, the ring element and theflexible member each are made of a material comprising metal or metalalloy.
 13. The flexible connection unit of claim 12 wherein theresilient element comprises elastomeric cladding.
 14. The flexibleconnection unit of claim 1 wherein the flexible member is positionedaxially through the spacer and at least a portion of the first or secondend portions.
 15. The flexible connection unit of claim 1 wherein theresilient element is concentric with the flexible member.
 16. Theflexible connection unit of claim 1 wherein the flexible member iseccentrically located in an axial cavity of the at least one spacer. 17.The flexible connection unit of claim 1 wherein the flexible member isphysically separated from both the first end portion and the second endportion.
 18. The flexible connection unit of claim 17 wherein theflexible member is surrounded with an elastomer.
 19. The flexibleconnection unit of claim 18 wherein the flexible member is formed of atleast one wire and the at least one wire is axially slidable within apre-formed extruded elastomer.
 20. The flexible connection unit of claim1 wherein the flexible member is in contact with at least one of thefirst and second end portions.
 21. The flexible connection unit of claim1 wherein the flexible member is fixed with respect to at least one ofthe first and second end portions.
 22. The flexible connection unit ofclaim 1 wherein the flexible member is fixed at both the first endportion and the second end portion.
 23. The flexible connection unit ofclaim 1 wherein the ring element circumferentially surrounds theresilient element.
 24. The flexible connection unit of claim 1 whereinthe spacer comprises a plurality of ring elements and the resilientelement comprises an elastomer.
 25. The flexible connection unit ofclaim 9 wherein the resilient element is polycarbonate urethane.
 26. Theflexible connection unit of claim 1, wherein the resilient element isconfigured to abut the first and second end portions of the longitudinalmember such that the resilient element is at least partially disposedwithin a cavity of the first or second end.
 27. The flexible connectionunit of claim 1, wherein the resilient element is configured to abut thefirst and second end portions of the longitudinal member such that thefirst or second end portion is at least partially disposed within acavity of the resilient member.